Healthcare Provider Details

I. General information

NPI: 1760494744
Provider Name (Legal Business Name): GEORGE MANDEL DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 CAMINO ENTRADA
SANTA FE NM
87507
US

IV. Provider business mailing address

PO BOX 29269
SANTA FE NM
87592-9269
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-2032
  • Fax: 505-474-8836
Mailing address:
  • Phone: 505-984-2032
  • Fax: 505-474-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number879
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: