Healthcare Provider Details

I. General information

NPI: 1508812397
Provider Name (Legal Business Name): VAN R WARREN DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N UNION AVE
ROSWELL NM
88201-3957
US

IV. Provider business mailing address

PO BOX 3112
ROSWELL NM
88202
US

V. Phone/Fax

Practice location:
  • Phone: 575-927-7109
  • Fax: 575-627-8439
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number169RX1
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: