Provider Demographics
NPI:1982930160
Name:SYNERGY WELLNESS CENTER LLC
Entity type:Organization
Organization Name:SYNERGY WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:ISABEL
Authorized Official - Last Name:GERSTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM MS
Authorized Official - Phone:505-292-9700
Mailing Address - Street 1:3600 RODEO LANE
Mailing Address - Street 2:5B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-5801
Mailing Address - Country:US
Mailing Address - Phone:505-292-9700
Mailing Address - Fax:505-867-2566
Practice Address - Street 1:3600 RODEO LN
Practice Address - Street 2:5B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-6400
Practice Address - Country:US
Practice Address - Phone:505-292-9700
Practice Address - Fax:505-867-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM307213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10007865Medicaid
NMNMB2399Medicare PIN
NM10007865Medicaid