Provider Demographics
NPI:1982185948
Name:FOS WELLNESS, LTD
Entity Type:Organization
Organization Name:FOS WELLNESS, LTD
Other - Org Name:TRINITY CHRISTIAN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIZER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP-BC, CFNC
Authorized Official - Phone:575-607-8702
Mailing Address - Street 1:1698 S ROOSEVELT ROAD 13
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-8705
Mailing Address - Country:US
Mailing Address - Phone:575-607-8702
Mailing Address - Fax:800-421-8110
Practice Address - Street 1:1698 S ROOSEVELT ROAD 13
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-8705
Practice Address - Country:US
Practice Address - Phone:575-607-8702
Practice Address - Fax:800-421-8110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOS WELLNESS, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-27
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-72322163W00000X, 163WD0400X, 163WN1003X, 163WG0000X, 390200000X, 163WN1003X
261QP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WN1003XNursing Service ProvidersRegistered NurseNutrition SupportGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty