Healthcare Provider Details

I. General information

NPI: 1710137369
Provider Name (Legal Business Name): JAN C JAY DOM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11110 SAN RAFAEL AVE NE
ALBUQUERQUE NM
87122-2400
US

IV. Provider business mailing address

11110 SAN RAFAEL AVE NE
ALBUQUERQUE NM
87122-2400
US

V. Phone/Fax

Practice location:
  • Phone: 505-323-8100
  • Fax:
Mailing address:
  • Phone: 505-323-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1020
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3556
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number637 RX2
License Number StateNM

VIII. Authorized Official

Name: DR. JAN C JAY
Title or Position: PRESIDENT
Credential: DOM
Phone: 505-323-8100