Healthcare Provider Details

I. General information

NPI: 1104131499
Provider Name (Legal Business Name): PAMELA BARRETT DOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 GENERAL STILWELL ST NE
ALBUQUERQUE NM
87123-1028
US

IV. Provider business mailing address

408 GENERAL STILWELL ST NE
ALBUQUERQUE NM
87123-1028
US

V. Phone/Fax

Practice location:
  • Phone: 505-850-8576
  • Fax:
Mailing address:
  • Phone: 505-850-8576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1028
License Number StateNM

VIII. Authorized Official

Name: MISS PAMELA SUE BARRETT
Title or Position: OWNER
Credential: D.O.M.
Phone: 505-850-8576