Healthcare Provider Details

I. General information

NPI: 1346580107
Provider Name (Legal Business Name): BLAIR SYLVAN GREY DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 LUISA ST SUITE 6
SANTA FE NM
87505-4091
US

IV. Provider business mailing address

369 MONTEZUMA AVE
SANTA FE NM
87501-2835
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-0226
  • Fax: 505-989-1470
Mailing address:
  • Phone: 505-992-0226
  • Fax: 505-989-1470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number599
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: