Healthcare Provider Details

I. General information

NPI: 1194136234
Provider Name (Legal Business Name): WENTAO LUO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 MEADOWLARK LN SE STE 4D
RIO RANCHO NM
87124-1050
US

IV. Provider business mailing address

7408 HAWTHORN AVE NE
ALBUQUERQUE NM
87113-2032
US

V. Phone/Fax

Practice location:
  • Phone: 150-540-0646
  • Fax:
Mailing address:
  • Phone: 150-540-0646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1135
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: