Provider Demographics
NPI:1306071139
Name:LIVING & WELLNESS CENTER
Entity type:Organization
Organization Name:LIVING & WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DIMITRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLAROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-640-3537
Mailing Address - Street 1:1100 S. MAIN EXECUTIVE SUITES
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2917
Mailing Address - Country:US
Mailing Address - Phone:575-525-5635
Mailing Address - Fax:575-647-8804
Practice Address - Street 1:1100 S. MAIN EXECUTIVE SUITES
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2917
Practice Address - Country:US
Practice Address - Phone:575-525-5635
Practice Address - Fax:575-647-8804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health