Provider Demographics
NPI:1962730010
Name:TIGER DEN WELLNESS CENTER
Entity type:Organization
Organization Name:TIGER DEN WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:ABREU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-454-3523
Mailing Address - Street 1:P.O. BOX 927
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701
Mailing Address - Country:US
Mailing Address - Phone:505-426-2262
Mailing Address - Fax:505-454-1473
Practice Address - Street 1:1535 TIGER CIRCLE
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740
Practice Address - Country:US
Practice Address - Phone:575-445-3641
Practice Address - Fax:575-445-8641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-01
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCL00010535251300000X
261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No251300000XAgenciesLocal Education Agency (LEA)