Healthcare Provider Details

I. General information

NPI: 1467652289
Provider Name (Legal Business Name): TERRA ROSA HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 N ALAMEDA BLVD STE 14
LAS CRUCES NM
88005-2193
US

IV. Provider business mailing address

741 N ALAMEDA BLVD STE 14
LAS CRUCES NM
88005-2193
US

V. Phone/Fax

Practice location:
  • Phone: 505-522-1100
  • Fax: 505-522-0100
Mailing address:
  • Phone: 505-522-1100
  • Fax: 505-522-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberR32956
License Number StateNM

VIII. Authorized Official

Name: GAIL M ELLISON
Title or Position: PRACTITIONER
Credential: CFNP
Phone: 505-522-1100