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General NPI Number Information
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NPI Number | 1982152237
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Entity Type | Organization
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Legal Business Name | EMBODIED SOUL CHIROPRACTIC
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Dates
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Enumeration Date | 09/15/2016
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Last Update Date | 09/15/2016
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Provider Practice Location Address
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Address Line | 5305 HERITAGE CT NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-3178
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Country | US
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Telephone | 505-822-5001
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Fax |
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Provider Business Mailing Address
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Address Line | 5305 HERITAGE CT NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-3178
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Country | US
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Telephone | 505-822-5001
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Fax |
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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC
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Name | DR. RANDALL ADAM POLGAR
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Credential | D.C.
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Telephone | 408-373-1358
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2146
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License Number State | NM
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