MEDICARE: AMY O'NEILL D.O.M, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NMOORJ29	OTHER	NM	BCBS
2	ZZ171100000X	OTHER	NM	PRES

General Provider Information

NPI Number	:	1699964460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMY O'NEILL D.O.M, LLC

Provider Business Mailing Address
First Line	:	275 BLUE SKY LN
Second Line	:
City	:	MESILLA PARK
State	:	NM
Zip	:	88047-9751
Country	:	US
Telephone Number	:	505-527-0821
Fax Number	:	505-524-2059

Provider Business Practice Location Address
First Line	:	200 W LAS CRUCES AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-1803
Country	:	US
Telephone Number	:	505-496-8161
Fax Number	:	505-524-2059

Authorized Official
Title or Position	:	DOCTOR OF ORIENTAL MEDICINE
Name	:	DR. AMY NICHOLS O'NEILL
Credential	:	D.O.M.
Telephone Number	:	505-527-0821

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	10/17/2007

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