Healthcare Provider Details

I. General information

NPI: 1740428606
Provider Name (Legal Business Name): INNERGLOW CHIROPRACTIC, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 DEBORAH RD SE SUITE 202A
RIO RANCHO NM
87124-1058
US

IV. Provider business mailing address

1424 DEBORAH RD SE SUITE 202A
RIO RANCHO NM
87124-1058
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-8081
  • Fax: 505-892-8270
Mailing address:
  • Phone: 505-892-8081
  • Fax: 505-892-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1716
License Number StateNM

VIII. Authorized Official

Name: DR. CASEY G LITTLE
Title or Position: OWNER
Credential: D.C.
Phone: 505-892-8081