=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811924392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAN R WARREN DOM PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 10/30/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 N. PENNSYLVANIA
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-627-7109
-----------------------------------------------------
Fax | 575-627-8439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3112
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-627-7109
-----------------------------------------------------
Fax | 575-627-8439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | BETH BLATCHFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-627-7109
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------