Healthcare Provider Details

I. General information

NPI: 1760726947
Provider Name (Legal Business Name): STEPHEN MONROE SUMMERS DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2012
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 CARLISLE BLVD NE STE A
ALBUQUERQUE NM
87107-4535
US

IV. Provider business mailing address

3916 CARLISLE BLVD NE STE A
ALBUQUERQUE NM
87107-4535
US

V. Phone/Fax

Practice location:
  • Phone: 505-310-9008
  • Fax: 888-314-6745
Mailing address:
  • Phone: 505-310-9008
  • Fax: 888-314-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number239
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: