Healthcare Provider Details

I. General information

NPI: 1447443619
Provider Name (Legal Business Name): DEVIN DENNIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 RIVER LN
RUIDOSO DOWNS NM
88346
US

IV. Provider business mailing address

429 RIVER LN
RUIDOSO DOWNS NM
88346
US

V. Phone/Fax

Practice location:
  • Phone: 505-973-0099
  • Fax:
Mailing address:
  • Phone: 505-059-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MISS DEVIN ELISABETH DENNIS
Title or Position: CASE MANGER
Credential:
Phone: 505-973-0099