Provider Demographics
NPI:1902000680
Name:DANIEL JUNCK LLC
Entity Type:Organization
Organization Name:DANIEL JUNCK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JUNCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-670-6549
Mailing Address - Street 1:223 N GUADALUPE ST
Mailing Address - Street 2:SUITE 466
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1868
Mailing Address - Country:US
Mailing Address - Phone:505-670-6549
Mailing Address - Fax:505-830-4803
Practice Address - Street 1:223 N GUADALUPE ST
Practice Address - Street 2:SUITE 466
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1868
Practice Address - Country:US
Practice Address - Phone:505-670-6549
Practice Address - Fax:505-830-4803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2005-0474261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46257268Medicaid
NM900521535Medicare PIN