Healthcare Provider Details

I. General information

NPI: 1679439400
Provider Name (Legal Business Name): CAMILLE ROSS COFFEY DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2025
Last Update Date: 12/24/2025
Certification Date: 12/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MOSS ROSE LN
TIJERAS NM
87059-7946
US

IV. Provider business mailing address

11 MOSS ROSE LN
TIJERAS NM
87059-7946
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-0190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC-2025-033
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: