=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851100432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEQUILA'S WHOLE HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2025
-----------------------------------------------------
Last Update Date | 12/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 438 PYRAMID WAY STE B
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89431-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-241-8153
-----------------------------------------------------
Fax | 775-547-2050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 438 PYRAMID WAY STE B
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89431-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-241-8153
-----------------------------------------------------
Fax | 775-547-2050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TEQUILA MARIE ROGERS
-----------------------------------------------------
Credential | APRN, FNP-BC
-----------------------------------------------------
Telephone | 304-573-1992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------