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General NPI Number Information
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NPI Number | 1982185948
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Entity Type | Organization
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Legal Business Name | FOS WELLNESS, LTD
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Dates
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Enumeration Date | 08/27/2018
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Last Update Date | 11/04/2021
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Provider Practice Location Address
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Address Line | 1698 S ROOSEVELT ROAD 13
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City | PORTALES
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State | NM
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Zip | 88130-8705
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Country | US
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Telephone | 575-607-8702
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Fax | 800-421-8110
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Provider Business Mailing Address
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Address Line | 1698 S ROOSEVELT ROAD 13
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City | PORTALES
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State | NM
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Zip | 88130-8705
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Country | US
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Telephone | 575-607-8702
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Fax | 800-421-8110
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. REBECCA KIZER
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Credential | MSN, FNP-BC, CFNC
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Telephone | 575-607-8702
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN-72322
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 163WD0400X
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Taxonomy Name | Diabetes Educator Registered Nurse
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License Number | RN-72322
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License Number State | NM
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Taxonomy #4
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Taxonomy Code | 163WN1003X
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Taxonomy Name | Nutrition Support Registered Nurse
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License Number | RN-72322
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License Number State | NM
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Taxonomy #5
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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