Provider Demographics
NPI:1154595825
Name:SYNERGY WELLNESS CENTER LLC
Entity type:Organization
Organization Name:SYNERGY WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:ISABEL
Authorized Official - Last Name:GERSTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM MS
Authorized Official - Phone:505-892-9700
Mailing Address - Street 1:4801 LANG AVE NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4474
Mailing Address - Country:US
Mailing Address - Phone:505-892-9700
Mailing Address - Fax:505-892-1210
Practice Address - Street 1:4801 LANG AVE NE
Practice Address - Street 2:SUITE 110
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4474
Practice Address - Country:US
Practice Address - Phone:505-892-9700
Practice Address - Fax:505-892-1210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM307261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07835761Medicaid
NM71889Medicare UPIN
NM07835761Medicaid
6248950001Medicare NSC