Healthcare Provider Details

I. General information

NPI: 1063677516
Provider Name (Legal Business Name): LUZ DE VIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 MIDDLE SAN PEDRO
ESPANOLA NM
87532
US

IV. Provider business mailing address

PO BOX 2901
ESPANOLA NM
87532
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-7242
  • Fax: 505-747-7242
Mailing address:
  • Phone: 505-747-7242
  • Fax: 505-747-7241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number240
License Number StateNM

VIII. Authorized Official

Name: PALOMA TERESE BLAIRE
Title or Position: OWNER PHYSICIAN
Credential: DO M
Phone: 505-747-7242