Healthcare Provider Details

I. General information

NPI: 1972786812
Provider Name (Legal Business Name): DONALD GENE CORNWELL DOM LMT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DON CORNWELL DOM LMT PHD

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 MORNINGSIDE SE
ALBUQUERQUE NM
87108-2633
US

IV. Provider business mailing address

202 MORNINGSIDE SE
ALBUQUERQUE NM
87108-2633
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-6870
  • Fax: 505-268-0818
Mailing address:
  • Phone: 505-268-6870
  • Fax: 505-268-0818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number210
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0668
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: