Healthcare Provider Details

I. General information

NPI: 1235649468
Provider Name (Legal Business Name): MELISSA MARIE TRUJILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 COUNTY ROAD 356
DULCE NM
87528-3001
US

IV. Provider business mailing address

HC 71 BOX 201 13728 US HWY 64
DULCE NM
87528
US

V. Phone/Fax

Practice location:
  • Phone: 575-419-0320
  • Fax:
Mailing address:
  • Phone: 575-759-0099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: