Healthcare Provider Details

I. General information

NPI: 1255396719
Provider Name (Legal Business Name): JAMES D PARK DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 EAGLE ROCK AVE NE SUITE A6
ALBUQUERQUE NM
87113-2478
US

IV. Provider business mailing address

7343 WILD OLIVE AVE NE
ALBUQUERQUE NM
87113-2079
US

V. Phone/Fax

Practice location:
  • Phone: 505-797-5400
  • Fax: 505-797-2905
Mailing address:
  • Phone: 505-514-2900
  • Fax: 505-884-5159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number866 RX-1
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2074
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: