Provider Demographics
NPI:1336959667
Name:BELLALUNA LIL LIGHT LLC/DBA MOUNTAIN GRIT WELLNESS LLC
Entity type:Organization
Organization Name:BELLALUNA LIL LIGHT LLC/DBA MOUNTAIN GRIT WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SHARLENE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:575-491-2310
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:MAYHILL
Mailing Address - State:NM
Mailing Address - Zip Code:88339-0022
Mailing Address - Country:US
Mailing Address - Phone:575-491-2310
Mailing Address - Fax:
Practice Address - Street 1:3496 US HIGHWAY 82
Practice Address - Street 2:
Practice Address - City:MAYHILL
Practice Address - State:NM
Practice Address - Zip Code:88339
Practice Address - Country:US
Practice Address - Phone:575-687-4232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELLALUNA LIL LIGHT LLC/ DBA MOUNTAIN GRIT WELLNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty