Healthcare Provider Details

I. General information

NPI: 1700361300
Provider Name (Legal Business Name): DANIEL GEORGE WILCZAK DC, MSR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 N MAIN ST
LAS CRUCES NM
88001-1274
US

IV. Provider business mailing address

221 N MAIN ST
LAS CRUCES NM
88001-1274
US

V. Phone/Fax

Practice location:
  • Phone: 575-652-6433
  • Fax:
Mailing address:
  • Phone: 575-652-6433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: