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General NPI Number Information
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NPI Number | 1124332010
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Entity Type | Organization
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Legal Business Name | MANDALA MEDICINE, LLC
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Dates
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Enumeration Date | 08/03/2010
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Last Update Date | 08/03/2010
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Provider Practice Location Address
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Address Line | 618 PASEO DE PERALTA STE A
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City | SANTA FE
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State | NM
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Zip | 87501-1984
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Country | US
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Telephone | 505-795-6164
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Fax | 505-466-4697
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Provider Business Mailing Address
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Address Line | 223 N GUADALUPE ST # 222
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City | SANTA FE
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State | NM
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Zip | 87501-1868
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Country | US
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Telephone | 505-795-6164
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Fax | 505-466-4697
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Authorized Official
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Title or Position | DOCTOR OF ORIENTAL MEDICINE
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Name | DR. MAYA YU
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Credential | DOM
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Telephone | 505-795-6164
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 1019
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 832
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License Number State | NM
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