Healthcare Provider Details

I. General information

NPI: 1396082392
Provider Name (Legal Business Name): EMILY FERREIRA DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 ZAMORA LN
PERALTA NM
87042-8400
US

IV. Provider business mailing address

6616 VISTA DEL MONTE NE
ALBUQUERQUE NM
87109-3950
US

V. Phone/Fax

Practice location:
  • Phone: 505-903-5698
  • Fax:
Mailing address:
  • Phone: 505-440-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1096
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: