Healthcare Provider Details

I. General information

NPI: 1205200870
Provider Name (Legal Business Name): MARISSA LOYA D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 LUISA ST STE 4A
SANTA FE NM
87505-4091
US

IV. Provider business mailing address

PO BOX 329
SANTA FE NM
87504-0329
US

V. Phone/Fax

Practice location:
  • Phone: 970-376-4354
  • Fax:
Mailing address:
  • Phone: 970-376-4354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1155
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: