Healthcare Provider Details

I. General information

NPI: 1487977898
Provider Name (Legal Business Name): WILLIAM WACKOCKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2010
Last Update Date: 03/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-3333
US

IV. Provider business mailing address

2720 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-3333
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-7936
  • Fax: 505-265-9685
Mailing address:
  • Phone: 505-265-7936
  • Fax: 505-265-9685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: