MEDICARE: SOUTHWEST CENTER FOR INTEGRATIVE MEDICINE

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	208D00000X	General Practice Physician	BB7316436	NM

General Provider Information

NPI Number	:	1497026405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST CENTER FOR INTEGRATIVE MEDICINE

Provider Business Mailing Address
First Line	:	1012 EUBANK BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-5310
Country	:	US
Telephone Number	:	505-298-4325
Fax Number	:	505-294-5407

Provider Business Practice Location Address
First Line	:	1012 EUBANK BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-5310
Country	:	US
Telephone Number	:	505-298-4325
Fax Number	:	505-294-5407

Authorized Official
Title or Position	:	C.E.O./ OWNER
Name	:	DOMINIC STAPE
Credential	:	D.O.M.
Telephone Number	:	505-298-4325

Provider Enumeration Date	:	01/23/2012
Last Update Date	:	05/10/2012

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