Healthcare Provider Details

I. General information

NPI: 1790011575
Provider Name (Legal Business Name): LAND OF ENCHANTMENT SPINE SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 BOSQUE PLZ NW STE A
ALBUQUERQUE NM
87120-4297
US

IV. Provider business mailing address

3620 BOSQUE PLZ NW STE A
ALBUQUERQUE NM
87120-4297
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-6886
  • Fax: 877-296-3211
Mailing address:
  • Phone: 505-792-6886
  • Fax: 877-296-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DOUGLAS A SLAUGHTER
Title or Position: OWNER
Credential: MD
Phone: 505-792-6886