Healthcare Provider Details

I. General information

NPI: 1245674712
Provider Name (Legal Business Name): ROSWELL HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

IV. Provider business mailing address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-4811
  • Fax: 575-624-4596
Mailing address:
  • Phone: 575-624-4811
  • Fax: 575-624-4596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberLD-0882
License Number State

VIII. Authorized Official

Name: VICKI EATON
Title or Position: PATIENT ACCOUNT MANAGER
Credential:
Phone: 575-627-4111