Healthcare Provider Details

I. General information

NPI: 1912499328
Provider Name (Legal Business Name): CHARLES FRED NEWBERRY III DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1446 S SAINT FRANCIS DR
SANTA FE NM
87505-4038
US

IV. Provider business mailing address

332 1/2 CAMINO CERRITO
SANTA FE NM
87505-5912
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-2178
  • Fax:
Mailing address:
  • Phone: 505-216-0864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1225
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: