Healthcare Provider Details

I. General information

NPI: 1952524902
Provider Name (Legal Business Name): JOHN SMITH B.S. , D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 LOWER LAS COLONIAS RD.
EL PRADO NM
87529
US

IV. Provider business mailing address

4396 NDCBU
TAOS NM
87571-6016
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-2038
  • Fax:
Mailing address:
  • Phone: 505-758-2038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number#028
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: