Healthcare Provider Details

I. General information

NPI: 1083869044
Provider Name (Legal Business Name): ELEONORE ISHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 SHEFFIELD DR STE F
CLOVIS NM
88101-4946
US

IV. Provider business mailing address

1800 SHEFFIELD DR STE F
CLOVIS NM
88101-4946
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-2660
  • Fax:
Mailing address:
  • Phone: 575-762-2660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License NumberLMT 6158
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: