Healthcare Provider Details

I. General information

NPI: 1619621588
Provider Name (Legal Business Name): MOUNTAIN PATH ACUPUNCTURE AND CHINESE MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 01/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7820 PAN AMERICAN FWY NE STE 3
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

7820 PAN AMERICAN FWY NE STE 3
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-6369
  • Fax: 505-944-1965
Mailing address:
  • Phone: 505-503-6369
  • Fax: 505-944-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT JAMES BIBEAU
Title or Position: OWNER
Credential: DOM
Phone: 505-503-6369