Healthcare Provider Details

I. General information

NPI: 1366817918
Provider Name (Legal Business Name): BEN DOUGLASS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W CORDOVA RD
SANTA FE NM
87505-1850
US

IV. Provider business mailing address

201 RICARDO RD
SANTA FE NM
87501-1737
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-8998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number083440003
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: