Healthcare Provider Details

I. General information

NPI: 1720351869
Provider Name (Legal Business Name): PAMELA JEAN GREGG FLAX D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 LUISA ST STE 21
SANTA FE NM
87505-4177
US

IV. Provider business mailing address

4751 AGUA FRIA ST
SANTA FE NM
87507-9251
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-8048
  • Fax:
Mailing address:
  • Phone: 505-690-8048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1072
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: