Healthcare Provider Details

I. General information

NPI: 1164150421
Provider Name (Legal Business Name): ROXANA PERALTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 HICKORY LOOP
LAS CRUCES NM
88005-6587
US

IV. Provider business mailing address

301 PERKINS DR STE B
LAS CRUCES NM
88005-3248
US

V. Phone/Fax

Practice location:
  • Phone: 575-625-3155
  • Fax: 505-441-2871
Mailing address:
  • Phone: 575-652-3155
  • Fax: 505-441-2871

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: