Healthcare Provider Details

I. General information

NPI: 1992194252
Provider Name (Legal Business Name): GURUMITTAR K KHALSA DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 LLANO ST
SANTA FE NM
87505-2003
US

IV. Provider business mailing address

1505 LLANO ST
SANTA FE NM
87505-2003
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-0605
  • Fax:
Mailing address:
  • Phone: 505-982-6369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1160
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: