Healthcare Provider Details

I. General information

NPI: 1306948948
Provider Name (Legal Business Name): ROBIN PATRICIA WALLACE D.O.M., LIC. AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 GLORY LANE
GLORIETA NM
87535
US

IV. Provider business mailing address

PO BOX 422
GLORIETA NM
87535
US

V. Phone/Fax

Practice location:
  • Phone: 505-231-6684
  • Fax: 505-884-4015
Mailing address:
  • Phone: 505-231-6684
  • Fax: 505-884-4015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAK000355L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberKO000048L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: