Healthcare Provider Details

I. General information

NPI: 1770693764
Provider Name (Legal Business Name): MARIANNE LAURA HAFER DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 MORELIA ST
SANTA FE NM
87505-4129
US

IV. Provider business mailing address

1207 MORELIA ST
SANTA FE NM
87505-4129
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-0764
  • Fax: 505-989-9953
Mailing address:
  • Phone: 505-820-0764
  • Fax: 505-989-9953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number243
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: