Healthcare Provider Details

I. General information

NPI: 1144165788
Provider Name (Legal Business Name): RUSTIC HEALTH PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 CUBA AVE
ALAMOGORDO NM
88310-5727
US

IV. Provider business mailing address

1301 CUBA AVE
ALAMOGORDO NM
88310-5727
US

V. Phone/Fax

Practice location:
  • Phone: 575-489-8993
  • Fax: 575-205-0274
Mailing address:
  • Phone: 575-489-8993
  • Fax: 575-205-0274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DAVID JOHN DONAVAN
Title or Position: OWNER
Credential:
Phone: 575-489-8993