Healthcare Provider Details

I. General information

NPI: 1306859863
Provider Name (Legal Business Name): JOHN JAMES MINCE-ENNIS D.O.M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 1/2 7TH ST
LAS VEGAS NM
87701-4238
US

IV. Provider business mailing address

PO BOX 4173
LAS VEGAS NM
87701-7173
US

V. Phone/Fax

Practice location:
  • Phone: 505-429-8859
  • Fax: 575-421-8852
Mailing address:
  • Phone: 505-429-8859
  • Fax: 575-421-8852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number809
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: