Healthcare Provider Details

I. General information

NPI: 1417530304
Provider Name (Legal Business Name): BACK AND NECK MEDICAL CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2803 DORAL CT
LAS CRUCES NM
88011-8616
US

IV. Provider business mailing address

1180 COMMERCE DR UNIT 14222
LAS CRUCES NM
88013-4649
US

V. Phone/Fax

Practice location:
  • Phone: 46-984-4063
  • Fax: 877-532-2113
Mailing address:
  • Phone: 505-695-1227
  • Fax: 877-532-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN J. WALDT
Title or Position: PROVIDER OWNER
Credential: DO
Phone: 505-695-1227