Healthcare Provider Details

I. General information

NPI: 1124369830
Provider Name (Legal Business Name): MICHAEL'S ACUPUNTURE AND FITNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 EARLY ST
SANTA FE NM
87505-1637
US

IV. Provider business mailing address

PO BOX 32431
SANTA FE NM
87594-2431
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-9058
  • Fax:
Mailing address:
  • Phone: 505-660-9058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1006
License Number StateNM

VIII. Authorized Official

Name: MICHAEL HANER
Title or Position: DOCTOR OR ORIENTAL MEDICINE
Credential: M.S.O.M.
Phone: 505-660-9058