Healthcare Provider Details

I. General information

NPI: 1447216254
Provider Name (Legal Business Name): BRANDON DEAN TAYLOR D.O.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N GUADALUPE ST SUITE C
SANTA FE NM
87501-1827
US

IV. Provider business mailing address

1279 SENDA DEL VALLE
SANTA FE NM
87507-7181
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-4357
  • Fax: 505-986-6005
Mailing address:
  • Phone: 505-438-2646
  • Fax: 505-986-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number883
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: