Healthcare Provider Details

I. General information

NPI: 1306035696
Provider Name (Legal Business Name): JESSE HOOVER D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 CAMINO CARLOS REY SUITE #20
SANTA FE NM
87507-5257
US

IV. Provider business mailing address

2241 CAMINO CARLOS REY SUITE #20
SANTA FE NM
87507-5257
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-3778
  • Fax:
Mailing address:
  • Phone: 505-471-3778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number936
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: