Healthcare Provider Details

I. General information

NPI: 1255873105
Provider Name (Legal Business Name): SARAH ROSE PETERSEN D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 ARROYO HONDO RD
SANTA FE NM
87508-5941
US

IV. Provider business mailing address

132 ARROYO HONDO RD
SANTA FE NM
87508-5941
US

V. Phone/Fax

Practice location:
  • Phone: 512-689-0001
  • Fax:
Mailing address:
  • Phone: 512-689-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1193
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: