Healthcare Provider Details

I. General information

NPI: 1912046467
Provider Name (Legal Business Name): J. MANNING HUDSON DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S SILVER AVE
DEMING NM
88030-3716
US

IV. Provider business mailing address

PO BOX 810
CERRILLOS NM
87010-0810
US

V. Phone/Fax

Practice location:
  • Phone: 505-546-2211
  • Fax:
Mailing address:
  • Phone: 505-660-4363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number717
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: