Healthcare Provider Details

I. General information

NPI: 1629216692
Provider Name (Legal Business Name): LIBERTY CHIROPRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 01/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WASHINGTON AVE
ROSWELL NM
88201-3250
US

IV. Provider business mailing address

PO BOX 3265
ROSWELL NM
88202-3265
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-8118
  • Fax: 575-622-6946
Mailing address:
  • Phone: 575-622-8118
  • Fax: 575-622-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number1500
License Number StateNM

VIII. Authorized Official

Name: DR. TERRY W. TODD
Title or Position: SOLO MEMBER
Credential: D.C.
Phone: 575-622-8118