Provider Demographics
NPI:1790011575
Name:LAND OF ENCHANTMENT SPINE SURGERY PC
Entity Type:Organization
Organization Name:LAND OF ENCHANTMENT SPINE SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:SLAUGHTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-792-6886
Mailing Address - Street 1:3620 BOSQUE PLZ NW STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4297
Mailing Address - Country:US
Mailing Address - Phone:505-792-6886
Mailing Address - Fax:877-296-3211
Practice Address - Street 1:3620 BOSQUE PLZ NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4297
Practice Address - Country:US
Practice Address - Phone:505-792-6886
Practice Address - Fax:877-296-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-28
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA100270Medicare PIN