Healthcare Provider Details

I. General information

NPI: 1689009896
Provider Name (Legal Business Name): VICTORIA KOO DOM, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 ACADEMY RD NE 922
ALBUQUERQUE NM
87111-7552
US

IV. Provider business mailing address

11600 ACADEMY RD NE 922
ALBUQUERQUE NM
87111-7552
US

V. Phone/Fax

Practice location:
  • Phone: 505-359-1608
  • Fax:
Mailing address:
  • Phone: 505-359-1608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1215
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7593
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: