Healthcare Provider Details

I. General information

NPI: 1528442035
Provider Name (Legal Business Name): KAI-YUAN CHENG DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 BELLAMAH AVE NW
ALBUQUERQUE NM
87104-2133
US

IV. Provider business mailing address

1240 BELLAMAH AVE NW
ALBUQUERQUE NM
87104-2133
US

V. Phone/Fax

Practice location:
  • Phone: 505-377-9835
  • Fax:
Mailing address:
  • Phone: 505-377-9835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1158
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: