Provider Demographics
NPI:1215649629
Name:RUSTIC HEALTH LLC
Entity type:Organization
Organization Name:RUSTIC HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:DONAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:575-479-7773
Mailing Address - Street 1:405 N DATE ST STE 4
Mailing Address - Street 2:
Mailing Address - City:T OR C
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2378
Mailing Address - Country:US
Mailing Address - Phone:575-297-4993
Mailing Address - Fax:575-205-0274
Practice Address - Street 1:405 N DATE ST STE 4
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-2378
Practice Address - Country:US
Practice Address - Phone:575-297-4993
Practice Address - Fax:575-205-0274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care