Provider Demographics
NPI:1609199447
Name:FAMILY PRACTICE MEDICAL AND DIETETIC MEDICAL THERAPY
Entity Type:Organization
Organization Name:FAMILY PRACTICE MEDICAL AND DIETETIC MEDICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:575-532-5386
Mailing Address - Street 1:2904 HILLRISE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4702
Mailing Address - Country:US
Mailing Address - Phone:575-532-5386
Mailing Address - Fax:575-532-5449
Practice Address - Street 1:2904 HILLRISE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4702
Practice Address - Country:US
Practice Address - Phone:575-532-5386
Practice Address - Fax:575-532-5449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06119133V00000X
NMLD0748133V00000X
NMCNP00942363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1609199447OtherBCBS
NM58878335Medicaid
NM1609199447OtherBCBS