Provider Demographics
NPI:1417071333
Name:CHAMBERLAIN, SELAH (DOM, L AC)
Entity Type:Individual
Prefix:
First Name:SELAH
Middle Name:
Last Name:CHAMBERLAIN
Suffix:
Gender:M
Credentials:DOM, L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3053
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-3053
Mailing Address - Country:US
Mailing Address - Phone:505-751-3284
Mailing Address - Fax:
Practice Address - Street 1:206 PASEO DEL PUEBLO NORTE
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5902
Practice Address - Country:US
Practice Address - Phone:505-751-3284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM379171100000X
CAAC 3247171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist