Healthcare Provider Details

I. General information

NPI: 1124332010
Provider Name (Legal Business Name): MANDALA MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 PASEO DE PERALTA STE A
SANTA FE NM
87501-1984
US

IV. Provider business mailing address

223 N GUADALUPE ST # 222
SANTA FE NM
87501-1868
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-6164
  • Fax: 505-466-4697
Mailing address:
  • Phone: 505-795-6164
  • Fax: 505-466-4697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1019
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number832
License Number StateNM

VIII. Authorized Official

Name: DR. MAYA YU
Title or Position: DOCTOR OF ORIENTAL MEDICINE
Credential: DOM
Phone: 505-795-6164