Provider Demographics
NPI:1710138706
Name:CLOVIS CHIROPRACTIC & HEALTHCARE CENTER PA
Entity Type:Organization
Organization Name:CLOVIS CHIROPRACTIC & HEALTHCARE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:575-769-1700
Mailing Address - Street 1:3001 N PRINCE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-1700
Mailing Address - Fax:575-769-1704
Practice Address - Street 1:3001 N PRINCE ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3827
Practice Address - Country:US
Practice Address - Phone:575-769-1700
Practice Address - Fax:575-769-1704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1617111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM343520201Medicare PIN