Healthcare Provider Details

I. General information

NPI: 1295211340
Provider Name (Legal Business Name): RIP & SNORT HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 11/15/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SOLANO RD
PIE TOWN NM
87827
US

IV. Provider business mailing address

PO BOX 781
PIE TOWN NM
87827-0781
US

V. Phone/Fax

Practice location:
  • Phone: 520-488-1756
  • Fax: 888-614-3881
Mailing address:
  • Phone: 520-488-1756
  • Fax: 888-614-3881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNM

VIII. Authorized Official

Name: DEVONNA ANNE JOHNSON
Title or Position: PROVIDER/ADMINISTRATOR
Credential: FNP-C
Phone: 520-488-1756