Healthcare Provider Details

I. General information

NPI: 1881773885
Provider Name (Legal Business Name): MARY JO MCILHON D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 SALAZAR ST FRONT
SANTA FE NM
87501-3641
US

IV. Provider business mailing address

521 SALAZAR ST FRONT
SANTA FE NM
87501-3641
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-8877
  • Fax:
Mailing address:
  • Phone: 505-984-8877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberNM714
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: