Healthcare Provider Details

I. General information

NPI: 1154544674
Provider Name (Legal Business Name): RAY MAZON DOM LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 VASSAR PL NE
ALBUQUERQUE NM
87107-1869
US

IV. Provider business mailing address

PO BOX 3501
ALBUQUERQUE NM
87190-3501
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-0048
  • Fax:
Mailing address:
  • Phone: 505-255-0048
  • Fax: 505-256-1487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number463
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: