Healthcare Provider Details

I. General information

NPI: 1114320389
Provider Name (Legal Business Name): GDI VENTURE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 GOLF COURSE RD SE STE. C
RIO RANCHO NM
87124-1956
US

IV. Provider business mailing address

1511 GOLF COURSE RD SE STE. C
RIO RANCHO NM
87124-1956
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-8600
  • Fax: 505-933-8601
Mailing address:
  • Phone: 505-933-8600
  • Fax: 505-933-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1664
License Number StateNM

VIII. Authorized Official

Name: DR. DEAN CRAIG WASSON
Title or Position: OWNER
Credential: D.C., NM-APC
Phone: 505-933-8600