MEDICARE: MR. DONALD GENE CORNWELL DOM LMT PHD

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	171100000X	Acupuncturist	210	NM
2	225700000X	Massage Therapist	0668	NM

General Provider Information

NPI Number	:	1972786812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD GENE CORNWELL DOM LMT PHD

Provider Business Mailing Address
First Line	:	202 MORNINGSIDE SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-2633
Country	:	US
Telephone Number	:	505-268-6870
Fax Number	:	505-268-0818

Provider Business Practice Location Address
First Line	:	202 MORNINGSIDE SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-2633
Country	:	US
Telephone Number	:	505-268-6870
Fax Number	:	505-268-0818

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2007
Last Update Date	:	12/14/2007

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Directions to “ MR. DONALD GENE CORNWELL DOM LMT PHD” Practice Location

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