Healthcare Provider Details

I. General information

NPI: 1174859136
Provider Name (Legal Business Name): ROSALITA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 OLD SANTA FE TRL # 171
SANTA FE NM
87505-0398
US

IV. Provider business mailing address

518 OLD SANTA FE TRL # 171
SANTA FE NM
87505-0398
US

V. Phone/Fax

Practice location:
  • Phone: 505-204-1239
  • Fax:
Mailing address:
  • Phone: 505-204-1239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number502
License Number StateNM

VIII. Authorized Official

Name: DR. FERAL A MACLOUD
Title or Position: DOCTOR OF ORIENTAL MEDICINE
Credential: DOM
Phone: 505-204-1239