Healthcare Provider Details

I. General information

NPI: 1588488977
Provider Name (Legal Business Name): GAIA TREE INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 CALLE MEDICO STE O
SANTA FE NM
87505-4706
US

IV. Provider business mailing address

1751 CALLE MEDICO STE O
SANTA FE NM
87505-4706
US

V. Phone/Fax

Practice location:
  • Phone: 505-391-4242
  • Fax: 505-439-7052
Mailing address:
  • Phone: 505-391-4242
  • Fax: 505-439-7052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CANDACE MILLER
Title or Position: OWNER
Credential: PA
Phone: 505-391-4242