Healthcare Provider Details

I. General information

NPI: 1720378482
Provider Name (Legal Business Name): CASEY LUNA REYNA D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 JEFFERSON ST NE STE 100
ALBUQUERQUE NM
87109-2130
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-7464
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1051
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: