Provider Demographics
NPI:1396503801
Name:SENIOR WELLNESS HOMECARE LLC
Entity type:Organization
Organization Name:SENIOR WELLNESS HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATRINA MAYE
Authorized Official - Middle Name:EUGENIO
Authorized Official - Last Name:DIVIDINA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:928-255-3684
Mailing Address - Street 1:1380 RIO RANCHO BLVD SE STE 485
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1006
Mailing Address - Country:US
Mailing Address - Phone:928-255-3684
Mailing Address - Fax:
Practice Address - Street 1:1005 21ST ST SE UNIT B1
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4030
Practice Address - Country:US
Practice Address - Phone:505-359-3586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care