Healthcare Provider Details

I. General information

NPI: 1093267809
Provider Name (Legal Business Name): JANINE MAHON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6855 4TH ST NW STE E1
LOS RANCHOS NM
87107-6167
US

IV. Provider business mailing address

338 LOS RANCHOS RD NW
LOS RANCHOS NM
87107-6531
US

V. Phone/Fax

Practice location:
  • Phone: 505-850-5572
  • Fax:
Mailing address:
  • Phone: 505-850-5572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1190
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: