| Wild Magnolia Wellness | |
|
6501 4th St Nw Ste H-5 Los Ranchos NM 87107-5800 | |
| (505) 274-0112 | |
| Not Available |
| Full Name | Wild Magnolia Wellness |
|---|---|
| Speciality | Clinic/Center |
| Location | 6501 4th St Nw Ste H-5, Los Ranchos, New Mexico |
| Authorized Official Name and Position | Ashley Susan Mckenna (OWNER) |
| Authorized Official Contact | 5052740112 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Wild Magnolia Wellness 5023 5th St Nw Albuquerque NM 87107-3803 Ph: (505) 274-0126 | Wild Magnolia Wellness 6501 4th St Nw Ste H-5 Los Ranchos NM 87107-5800 Ph: (505) 274-0112 |
| NPI Number | 1255820205 |
|---|---|
| Provider Enumeration Date | 05/04/2018 |
| Last Update Date | 11/13/2023 |
| Certification Date | 11/10/2023 |
| Medicare PECOS PAC ID | 8729492491 |
|---|---|
| Medicare Enrollment ID | O20210121001173 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255820205 | NPI | - | NPPES |
| 1730112483 | Medicaid | NM |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | 0139371 (New Mexico) | Primary |
| Provider Name | Sherry Lebeznick Brown |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1154504777 PECOS PAC ID: 3678878774 Enrollment ID: I20160229000371 |
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