Healthcare Provider Details

I. General information

NPI: 1003241910
Provider Name (Legal Business Name): SHANNON SMITH D.O.M., L.AC., L.M.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON RADHA SMITH-JORY L.M.T.

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 BRIDGE ST
LAS VEGAS NM
87701-3427
US

IV. Provider business mailing address

2421 JESSIE LEE LN
LAS VEGAS NM
87701-5026
US

V. Phone/Fax

Practice location:
  • Phone: 505-310-3239
  • Fax:
Mailing address:
  • Phone: 505-310-3239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1098
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0351
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: