Healthcare Provider Details

I. General information

NPI: 1417520081
Provider Name (Legal Business Name): ROBERT BIBEAU DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 12/08/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7820 PAN AMERICAN FWY, NE STE 3
ALBUQUERQUE NM
87109-4655
US

IV. Provider business mailing address

7717 ROBERTS ST. NE
ALBUQUERQUE NM
87109-5250
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-9642
  • Fax: 505-828-9191
Mailing address:
  • Phone: 505-681-5603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDOM1275
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: