Provider Demographics
NPI:1740428606
Name:INNERGLOW CHIROPRACTIC, L.L.C.
Entity Type:Organization
Organization Name:INNERGLOW CHIROPRACTIC, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:505-892-8081
Mailing Address - Street 1:1424 DEBORAH RD SE
Mailing Address - Street 2:SUITE 202A
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1058
Mailing Address - Country:US
Mailing Address - Phone:505-892-8081
Mailing Address - Fax:505-892-8270
Practice Address - Street 1:1424 DEBORAH RD SE
Practice Address - Street 2:SUITE 202A
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1058
Practice Address - Country:US
Practice Address - Phone:505-892-8081
Practice Address - Fax:505-892-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMB2030Medicare PIN