Healthcare Provider Details

I. General information

NPI: 1093259921
Provider Name (Legal Business Name): LAURA OLSON DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W SAN MATEO RD
SANTA FE NM
87505-4027
US

IV. Provider business mailing address

PO BOX 22187
SANTA FE NM
87502-2187
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-1234
  • Fax: 844-450-2837
Mailing address:
  • Phone: 505-983-1234
  • Fax: 844-450-2837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number465
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: