Healthcare Provider Details

I. General information

NPI: 1336528918
Provider Name (Legal Business Name): DIAMONDBACK WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 KINLEY AVE NW
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

633 KINLEY AVE NW
ALBUQUERQUE NM
87102-1282
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-1067
  • Fax:
Mailing address:
  • Phone: 505-242-1067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1000
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number230
License Number StateNM

VIII. Authorized Official

Name: DR. GINA T OGORZALY
Title or Position: MANAGER
Credential: D.C.
Phone: 505-242-1067