MEDICARE: TERRA ROSA HEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center	R32956	NM

General Provider Information

NPI Number	:	1467652289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TERRA ROSA HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	741 N ALAMEDA BLVD
Second Line	:	STE 14
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2193
Country	:	US
Telephone Number	:	505-522-1100
Fax Number	:	505-522-0100

Provider Business Practice Location Address
First Line	:	741 N ALAMEDA BLVD STE 14
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2193
Country	:	US
Telephone Number	:	505-522-1100
Fax Number	:	505-522-0100

Authorized Official
Title or Position	:	PRACTITIONER
Name	:	GAIL M ELLISON
Credential	:	CFNP
Telephone Number	:	505-522-1100

Provider Enumeration Date	:	07/19/2007
Last Update Date	:	10/23/2014

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