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General NPI Number Information
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NPI Number | 1336528918
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Entity Type | Organization
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Legal Business Name | DIAMONDBACK WELLNESS CENTER LLC
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Dates
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Enumeration Date | 05/28/2015
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Last Update Date | 05/28/2015
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Provider Practice Location Address
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Address Line | 633 KINLEY AVE NW
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City | ALBUQUERQUE
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State | NM
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Zip | 87102
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Country | US
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Telephone | 505-242-1067
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Fax |
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Provider Business Mailing Address
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Address Line | 633 KINLEY AVE NW
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-1282
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Country | US
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Telephone | 505-242-1067
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. GINA T OGORZALY
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Credential | D.C.
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Telephone | 505-242-1067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 230
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1000
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License Number State | NM
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