Healthcare Provider Details

I. General information

NPI: 1154897890
Provider Name (Legal Business Name): EMILY ROSE MILANO HORNBACK DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2018
Last Update Date: 10/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 LINDA DR
GALLUP NM
87301-5616
US

IV. Provider business mailing address

1406 LINDA DR
GALLUP NM
87301-5616
US

V. Phone/Fax

Practice location:
  • Phone: 541-610-8873
  • Fax:
Mailing address:
  • Phone: 541-610-8873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1224
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: