MEDICARE: ROSALITA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center	502	NM

General Provider Information

NPI Number	:	1174859136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSALITA LLC

Provider Business Mailing Address
First Line	:	518 OLD SANTA FE TRL # 171
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-0398
Country	:	US
Telephone Number	:	505-204-1239
Fax Number	:

Provider Business Practice Location Address
First Line	:	518 OLD SANTA FE TRL # 171
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-0398
Country	:	US
Telephone Number	:	505-204-1239
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR OF ORIENTAL MEDICINE
Name	:	DR. FERAL A MACLOUD
Credential	:	DOM
Telephone Number	:	505-204-1239

Provider Enumeration Date	:	10/27/2009
Last Update Date	:	11/02/2009

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Directions to “ROSALITA LLC ” Practice Location

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