Healthcare Provider Details

I. General information

NPI: 1881825123
Provider Name (Legal Business Name): LONGEVITY ACUPUNCTURE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 SAN MATEO BLVD NE
ALBUQUERQUE NM
87110-6429
US

IV. Provider business mailing address

1403 SAN MATEO BLVD NE
ALBUQUERQUE NM
87110-6429
US

V. Phone/Fax

Practice location:
  • Phone: 505-263-7248
  • Fax: 505-244-8731
Mailing address:
  • Phone: 505-263-7248
  • Fax: 505-244-8731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number639RX1
License Number StateNM

VIII. Authorized Official

Name: MELISSA ANN CRUM
Title or Position: PRESIDENT
Credential: D.O.M., L.AC.
Phone: 505-263-7248