Healthcare Provider Details

I. General information

NPI: 1245331909
Provider Name (Legal Business Name): ROBERT G. NUTTALL D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 JUAN TABO BLVD NE STE 117
ALBUQUERQUE NM
87112-1885
US

IV. Provider business mailing address

2901 JUAN TABO BLVD NE STE 117
ALBUQUERQUE NM
87112-1885
US

V. Phone/Fax

Practice location:
  • Phone: 505-275-9602
  • Fax: 505-275-9604
Mailing address:
  • Phone: 505-275-9602
  • Fax: 505-275-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number840
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: