Provider Demographics
NPI:1043713415
Name:SOUTHWEST RECOVERY AND WELLNESS LLC
Entity type:Organization
Organization Name:SOUTHWEST RECOVERY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-854-8587
Mailing Address - Street 1:914 PINEHURST RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2219
Mailing Address - Country:US
Mailing Address - Phone:323-854-8587
Mailing Address - Fax:505-896-2505
Practice Address - Street 1:3874 MASTHEAD ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4479
Practice Address - Country:US
Practice Address - Phone:505-896-9412
Practice Address - Fax:505-895-2505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1568643146Medicaid