Healthcare Provider Details

I. General information

NPI: 1144765983
Provider Name (Legal Business Name): CROSSROADS COMMUNITY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 PASEO DEL PUEBLO SUR
TAOS NM
87571-5328
US

IV. Provider business mailing address

330 PASEO DEL PUEBLO SUR
TAOS NM
87571-5328
US

V. Phone/Fax

Practice location:
  • Phone: 575-776-7806
  • Fax:
Mailing address:
  • Phone: 575-776-7806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1102
License Number StateNM

VIII. Authorized Official

Name: DR. LILLY-MARIE MAITA BLECHER
Title or Position: PRESIDENT
Credential: ND, DOM
Phone: 575-776-7806