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General NPI Number Information
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NPI Number | 1669288874
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Entity Type | Organization
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Legal Business Name | RUSTIC HEALTH DIAGNOSTICS LLC
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 405 N DATE ST STE 4
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City | T OR C
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State | NM
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Zip | 87901-2378
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Country | US
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Telephone | 575-297-4993
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Fax | 575-205-0274
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Provider Business Mailing Address
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Address Line | 405 N DATE ST STE 4
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City | T OR C
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State | NM
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Zip | 87901-2378
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Country | US
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Telephone | 575-297-4993
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Fax | 575-205-0274
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Authorized Official
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Title or Position | OWNER
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Name | DAVID JOHN DONAVAN
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Credential | LPN
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Telephone | 575-297-4993
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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