Healthcare Provider Details

I. General information

NPI: 1629023304
Provider Name (Legal Business Name): KARTAR SINGH KHALSA DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N PASEO DE ONATE
ESPANOLA NM
87532-2619
US

IV. Provider business mailing address

415 N PASEO DE ONATE
ESPANOLA NM
87532-2619
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-3369
  • Fax: 505-753-4006
Mailing address:
  • Phone: 505-753-3369
  • Fax: 505-753-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number450
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: