Provider Demographics
NPI:1962127878
Name:MARIPOSA TRANSFORMATION WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:MARIPOSA TRANSFORMATION WELLNESS CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PA-C / OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:505-234-6432
Mailing Address - Street 1:4550 EUBANK BLVD NE
Mailing Address - Street 2:SUITE D205
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-234-6432
Mailing Address - Fax:
Practice Address - Street 1:4550 EUBANK BLVD NE
Practice Address - Street 2:SUITE D205
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2565
Practice Address - Country:US
Practice Address - Phone:505-234-6432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty