Healthcare Provider Details

I. General information

NPI: 1255723672
Provider Name (Legal Business Name): LARRY F WIDMER DC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2015
Last Update Date: 02/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1892 PLAZA DEL SUR DR STE A
SANTA FE NM
87505-6073
US

IV. Provider business mailing address

1892 PLAZA DEL SUR DR STE A
SANTA FE NM
87505-6073
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-8017
  • Fax: 505-988-8018
Mailing address:
  • Phone: 505-988-8017
  • Fax: 505-988-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1406
License Number StateNM

VIII. Authorized Official

Name: DR. LARRY F WIDMER
Title or Position: PRESIDENT
Credential: DC
Phone: 717-368-4016