Healthcare Provider Details

I. General information

NPI: 1720575525
Provider Name (Legal Business Name): MELANIE LYNN RICHARDSON DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7528 4TH ST NW
LOS RANCHOS NM
87107-6683
US

IV. Provider business mailing address

7401 MESQUITE WOOD DR NW
ALBQUERQUE NM
87120-4054
US

V. Phone/Fax

Practice location:
  • Phone: 505-250-4051
  • Fax:
Mailing address:
  • Phone: 505-250-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number743
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: