Healthcare Provider Details

I. General information

NPI: 1992405401
Provider Name (Legal Business Name): NICOLETTE GEORGE DOM, MACOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR STE 1205
SANTA FE NM
87505-8605
US

IV. Provider business mailing address

8400 FAIRMONT DR NW
ALBUQUERQUE NM
87120-3833
US

V. Phone/Fax

Practice location:
  • Phone: 505-504-2754
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDOM1282
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: