Healthcare Provider Details

I. General information

NPI: 1780945659
Provider Name (Legal Business Name): SARAH GORDER D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2921 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-2865
US

IV. Provider business mailing address

P. O. BOX 93504
ALBUQUERQUE NM
87199
US

V. Phone/Fax

Practice location:
  • Phone: 505-510-2287
  • Fax:
Mailing address:
  • Phone: 505-504-8041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1062
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: