Healthcare Provider Details

I. General information

NPI: 1659138832
Provider Name (Legal Business Name): TRADITIONAL AMERICAN OSTEOPATHY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 CAMINO DE LOS MARQUEZ
SANTA FE NM
87505-1837
US

IV. Provider business mailing address

3201 ZAFARANO DR STE C PMB 249
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-405-8423
  • Fax: 505-485-0641
Mailing address:
  • Phone: 505-405-8423
  • Fax: 505-485-0641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY ANN ROBAK
Title or Position: PHYSICIAN/OWNER
Credential: DO
Phone: 414-614-5758