Healthcare Provider Details

I. General information

NPI: 1114355039
Provider Name (Legal Business Name): BIANCA SAMPAIO DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR STE 601
SANTA FE NM
87505-7652
US

IV. Provider business mailing address

460 SAINT MICHAELS DR STE 601
SANTA FE NM
87505-7652
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-3034
  • Fax: 505-984-3034
Mailing address:
  • Phone: 505-984-3034
  • Fax: 505-984-3034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1122
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: