Basic Information
| Provider Information | |||||||||
| NPI: | 1841840774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST WELLNESS WORKS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 BARNES AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
| FaxNumber: | 7193845672 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 KENDALL DR. | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810523901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
| FaxNumber: | 7193845672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2019 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | CHAVEZ | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT AND CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7193835448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 37400266 | 05 | CO | MEDICAID |