Provider Demographics
NPI:1760605885
Name:ESPANOLA FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:ESPANOLA FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:505-753-3001
Mailing Address - Street 1:628 N RIVERSIDE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2620
Mailing Address - Country:US
Mailing Address - Phone:505-753-3001
Mailing Address - Fax:505-753-3052
Practice Address - Street 1:628 N RIVERSIDE DR
Practice Address - Street 2:SUITE C
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2620
Practice Address - Country:US
Practice Address - Phone:505-753-3001
Practice Address - Fax:505-753-3052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1497261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM06904564Medicaid
NMU55173Medicare UPIN