MEDICARE: HEALING SOURCE CHIROPRACTIC PC

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	111N00000X	Chiropractor	1617	NM

General Provider Information

NPI Number	:	1982753141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING SOURCE CHIROPRACTIC PC

Provider Business Mailing Address
First Line	:	3961 E. LOHMAN AVE
Second Line	:	SUITE 22
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8272
Country	:	US
Telephone Number	:	575-652-3358
Fax Number	:	575-652-3360

Provider Business Practice Location Address
First Line	:	3961 E. LOHMAN AVE
Second Line	:	SUITE 22
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8272
Country	:	US
Telephone Number	:	575-652-3358
Fax Number	:	575-652-3360

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	WENDI C WALLIN
Credential	:	D.C.
Telephone Number	:	575-652-3358

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	01/10/2017

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