Healthcare Provider Details

I. General information

NPI: 1053505792
Provider Name (Legal Business Name): GRD ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
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 Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNM

VIII. Authorized Official

Name: MISS PATWANT KAUR KHALSA
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-753-3369