Healthcare Provider Details

I. General information

NPI: 1942447313
Provider Name (Legal Business Name): COLEENE ANN BURCH DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 LUISA ST STE 5A
SANTA FE NM
87505-4091
US

IV. Provider business mailing address

223 N GUADALUPE ST # 121
SANTA FE NM
87501-1868
US

V. Phone/Fax

Practice location:
  • Phone: 505-930-2639
  • Fax:
Mailing address:
  • Phone: 505-930-2639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number852
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: