Healthcare Provider Details

I. General information

NPI: 1205018777
Provider Name (Legal Business Name): SEVA SIMRAN SIRI SINGH KHALSA D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 03/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 SAN ILDEFONSO ST
ESPANOLA NM
87532-3213
US

IV. Provider business mailing address

1026 SAN ILDEFONSO ST
ESPANOLA NM
87532-3213
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-7944
  • Fax: 505-747-7944
Mailing address:
  • Phone: 505-747-7944
  • Fax: 505-747-7944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number907
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: