Healthcare Provider Details

I. General information

NPI: 1912011354
Provider Name (Legal Business Name): KAREN MARIE SERRANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 S. ST FRANCIS #E ANCIENT TIDE WELLNESS
SANTA FE NM
87505
US

IV. Provider business mailing address

1028 DON DIEGO AVE
SANTA FE NM
87505-1627
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-9966
  • Fax:
Mailing address:
  • Phone: 505-670-9966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number812
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: