Healthcare Provider Details

I. General information

NPI: 1477595601
Provider Name (Legal Business Name): BLUE MOUNTAIN CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ACOMA
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 1687
TAOS NM
87571-1687
US

V. Phone/Fax

Practice location:
  • Phone: 505-770-1660
  • Fax:
Mailing address:
  • Phone: 505-770-1660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1540
License Number StateNM

VIII. Authorized Official

Name: DR. SUSAN R HILLIKER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 505-770-1660