Provider Demographics
NPI:1417530304
Name:BACK AND NECK MEDICAL CARE CENTER, LLC
Entity Type:Organization
Organization Name:BACK AND NECK MEDICAL CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALDT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-695-1227
Mailing Address - Street 1:1180 COMMERCE DR UNIT 14222
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-4649
Mailing Address - Country:US
Mailing Address - Phone:505-695-1227
Mailing Address - Fax:877-532-2113
Practice Address - Street 1:2900 HILLRISE DRIVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:505-695-1227
Practice Address - Fax:877-532-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty