Healthcare Provider Details

I. General information

NPI: 1215649629
Provider Name (Legal Business Name): RUSTIC HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N DATE ST STE 4
T OR C NM
87901-2378
US

IV. Provider business mailing address

405 N DATE ST STE 4
T OR C NM
87901-2378
US

V. Phone/Fax

Practice location:
  • Phone: 575-297-4993
  • Fax: 575-205-0274
Mailing address:
  • Phone: 575-297-4993
  • Fax: 575-205-0274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DAVID J DONAVAN
Title or Position: OWNER/ADMINISTRATOR
Credential: LPN
Phone: 575-479-7773