Healthcare Provider Details

I. General information

NPI: 1508306846
Provider Name (Legal Business Name): JEAN MARIE LOSCALZO D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 LENA ST BUILDING C, SUITE 16
SANTA FE NM
87505-3891
US

IV. Provider business mailing address

1600 LENA ST BUILDING C, SUITE 16
SANTA FE NM
87505-3891
US

V. Phone/Fax

Practice location:
  • Phone: 718-809-5684
  • Fax:
Mailing address:
  • Phone: 718-809-5684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1192
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: