Healthcare Provider Details

I. General information

NPI: 1962684977
Provider Name (Legal Business Name): WALL CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CALIENTE RD STE 2B
SANTA FE NM
87508-9100
US

IV. Provider business mailing address

5 CALIENTE RD STE 2B
SANTA FE NM
87508-9100
US

V. Phone/Fax

Practice location:
  • Phone: 505-466-1429
  • Fax: 505-466-1437
Mailing address:
  • Phone: 505-466-1429
  • Fax: 505-466-1437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LISE S WALL
Title or Position: OWNER
Credential: D.C.
Phone: 505-466-1429