Healthcare Provider Details

I. General information

NPI: 1972537520
Provider Name (Legal Business Name): MEGUMI HIRAYAMA D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 MONTGOMERY BLVD NE SUITE B
ALBUQUERQUE NM
87109-6756
US

IV. Provider business mailing address

4135 MONTGOMERY BLVD NE SUITE B
ALBUQUERQUE NM
87109-6756
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-6888
  • Fax: 505-883-9088
Mailing address:
  • Phone: 505-888-6888
  • Fax: 505-883-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number517RX1
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: