Healthcare Provider Details

I. General information

NPI: 1588131908
Provider Name (Legal Business Name): DUSTIE JO MARES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST STE H2
SANTA FE NM
87505-2106
US

IV. Provider business mailing address

736 TERRACE DR
LAS VEGAS NM
87701-4934
US

V. Phone/Fax

Practice location:
  • Phone: 505-557-6140
  • Fax:
Mailing address:
  • Phone: 505-903-3892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8840
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: