Healthcare Provider Details

I. General information

NPI: 1700944972
Provider Name (Legal Business Name): WALTER BARKER EDDY DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 GALISTEO ST
SANTA FE NM
87505
US

IV. Provider business mailing address

27 SADDLEBACK MESA
SANTA FE NM
87508
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-8884
  • Fax:
Mailing address:
  • Phone: 505-986-1058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number699
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: