Healthcare Provider Details

I. General information

NPI: 1619005600
Provider Name (Legal Business Name): LAURENCE LISA LEBRETON DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 CAMINO DE LOS MARQUEZ SUITE 1
SANTA FE NM
87505-1831
US

IV. Provider business mailing address

369 MONTEZUMA AVE # 393
SANTA FE NM
87501-2626
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-7855
  • Fax:
Mailing address:
  • Phone: 505-577-7855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number790
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: