Healthcare Provider Details

I. General information

NPI: 1033706643
Provider Name (Legal Business Name): SUSAN M PISANO DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 GALISTEO ST STE 12
SANTA FE NM
87505-2113
US

IV. Provider business mailing address

3 PASILLO CHICO
SANTA FE NM
87508-9581
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-8589
  • Fax:
Mailing address:
  • Phone: 505-660-8589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC1234
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: