Healthcare Provider Details

I. General information

NPI: 1346638210
Provider Name (Legal Business Name): MARTIN RETHERFORD D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 KEEPING DR NW
ALBUQUERQUE NM
87114-4601
US

IV. Provider business mailing address

PO BOX 15386
RIO RANCHO NM
87174-0386
US

V. Phone/Fax

Practice location:
  • Phone: 909-223-9809
  • Fax:
Mailing address:
  • Phone: 505-433-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1154
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: