Healthcare Provider Details

I. General information

NPI: 1114418068
Provider Name (Legal Business Name): ADAM BRODER DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2018
Last Update Date: 05/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 FAYETTE ST
SANTA FE NM
87505-0930
US

IV. Provider business mailing address

814 FAYETTE ST
SANTA FE NM
87505-0930
US

V. Phone/Fax

Practice location:
  • Phone: 773-398-1790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1223
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: