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General NPI Number Information
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NPI Number | 1942477336
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Entity Type | Organization
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Legal Business Name | ORIGINAL MEDICINE CENTER FOR HEALING
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Dates
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Enumeration Date | 05/14/2008
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Last Update Date | 05/14/2008
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Provider Practice Location Address
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Address Line | 119 SAN PASQUALE AVE SW
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City | ALBUQUERQUE
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State | NM
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Zip | 87104-1153
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Country | US
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Telephone | 505-604-3434
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Fax | 505-242-2410
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Provider Business Mailing Address
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Address Line | 610 11TH ST NW
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-1808
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Country | US
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Telephone | 505-604-3434
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Fax | 505-242-2410
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR/OWNER
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Name | DR. REBA I. EAGLES
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Credential | D.O.M.
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Telephone | 505-604-3434
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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 | 833
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License Number State | NM
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