Healthcare Provider Details

I. General information

NPI: 1194866103
Provider Name (Legal Business Name): REBA I EAGLES D. O. M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 SAN PASQUALE AVE SW
ALBUQUERQUE NM
87104-1153
US

IV. Provider business mailing address

610 11TH ST NW
ALBUQUERQUE NM
87102-1808
US

V. Phone/Fax

Practice location:
  • Phone: 505-604-3434
  • Fax: 505-242-2410
Mailing address:
  • Phone: 505-604-3434
  • Fax: 505-242-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number833
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: