Provider Demographics
NPI:1689472904
Name:AQUARIUS MEDICAL & WELLNESS CLINIC, LLC
Entity type:Organization
Organization Name:AQUARIUS MEDICAL & WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:813-484-2335
Mailing Address - Street 1:955 RICHARDS AVE APT 2006
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-6216
Mailing Address - Country:US
Mailing Address - Phone:813-484-2335
Mailing Address - Fax:505-395-9251
Practice Address - Street 1:955 RICHARDS AVE APT 2006
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-6216
Practice Address - Country:US
Practice Address - Phone:813-484-2335
Practice Address - Fax:505-395-9251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care