Healthcare Provider Details

I. General information

NPI: 1710169610
Provider Name (Legal Business Name): IRENE WALKIW DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4775 INDIAN SCHOOL RD NE SUITE 100
ALBUQUERQUE NM
87110-3973
US

IV. Provider business mailing address

4775 INDIAN SCHOOL RD NE SUITE 100
ALBUQUERQUE NM
87110-3973
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-6700
  • Fax: 505-888-6701
Mailing address:
  • Phone: 505-888-6700
  • Fax: 505-888-6701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number853
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: