MEDICARE: MS. MARIANNE LAURA HAFER DOM

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	171100000X	Acupuncturist	243	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R624	OTHER	NM	BCBS OF NM

General Provider Information

NPI Number	:	1770693764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARIANNE LAURA HAFER DOM

Provider Business Mailing Address
First Line	:	1207 MORELIA ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4129
Country	:	US
Telephone Number	:	505-820-0764
Fax Number	:	505-989-9953

Provider Business Practice Location Address
First Line	:	1207 MORELIA ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4129
Country	:	US
Telephone Number	:	505-820-0764
Fax Number	:	505-989-9953

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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