Healthcare Provider Details

I. General information

NPI: 1326762063
Provider Name (Legal Business Name): RANDI DAWN WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 N HUDSON ST
SILVER CITY NM
88061-5436
US

IV. Provider business mailing address

607 N HUDSON ST STE B
SILVER CITY NM
88061-5436
US

V. Phone/Fax

Practice location:
  • Phone: 575-956-6478
  • Fax:
Mailing address:
  • Phone: 575-956-6478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7780
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: