Provider Demographics
NPI:1861607400
Name:BERNALILLO SPARTAN WELLNESS CENTER
Entity type:Organization
Organization Name:BERNALILLO SPARTAN 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 1:148 SPARTAN ALY
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6298
Practice Address - Country:US
Practice Address - Phone:505-426-2262
Practice Address - Fax:505-454-1473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH8226Medicaid