Healthcare Provider Details

I. General information

NPI: 1487908729
Provider Name (Legal Business Name): ELIZABETH TUTTLE DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 FREDS LOOP BOX 1012
PECOS NM
87552-1012
US

IV. Provider business mailing address

16 FREDS LOOP PO BOX 1012
PECOS NM
87552-1012
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-2140
  • Fax:
Mailing address:
  • Phone: 505-757-2140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number735
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: