Provider Demographics
NPI:1649796699
Name:MEDICAL ASSISTED WELLNESS LLC
Entity type:Organization
Organization Name:MEDICAL ASSISTED WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:423-388-5688
Mailing Address - Street 1:4216 AURIGA CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-0940
Mailing Address - Country:US
Mailing Address - Phone:423-388-5688
Mailing Address - Fax:
Practice Address - Street 1:121 WYATT DR STE 3
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2960
Practice Address - Country:US
Practice Address - Phone:575-495-2000
Practice Address - Fax:575-495-2000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-21
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty