Healthcare Provider Details

I. General information

NPI: 1679608202
Provider Name (Legal Business Name): MARA ELIZABETH ZIECKER D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 19TH AVE SE
RIO RANCHO NM
87124-1700
US

IV. Provider business mailing address

2802 19TH AVE SE
RIO RANCHO NM
87124-1700
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-9871
  • Fax: 505-891-9871
Mailing address:
  • Phone: 505-891-9871
  • Fax: 505-891-9871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number899
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: