Provider Demographics
NPI:1538761093
Name:NEW MEXICO WELLNESS
Entity type:Organization
Organization Name:NEW MEXICO WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELONIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BACOCCINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-362-0758
Mailing Address - Street 1:4210 MEADOWLARK LN SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1021
Mailing Address - Country:US
Mailing Address - Phone:505-362-0758
Mailing Address - Fax:
Practice Address - Street 1:4210 MEADOWLARK LN SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1021
Practice Address - Country:US
Practice Address - Phone:505-362-0758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder