Provider Demographics
NPI:1255723672
Name:LARRY F WIDMER DC LLC
Entity type:Organization
Organization Name:LARRY F WIDMER DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:F
Authorized Official - Last Name:WIDMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-368-4016
Mailing Address - Street 1:1892 PLAZA DEL SUR DR STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6073
Mailing Address - Country:US
Mailing Address - Phone:505-988-8017
Mailing Address - Fax:505-988-8018
Practice Address - Street 1:1892 PLAZA DEL SUR DR STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6073
Practice Address - Country:US
Practice Address - Phone:505-988-8017
Practice Address - Fax:505-988-8018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-22
Last Update Date:2015-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1406111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
035313F70OtherMEDICARE NUMBER
035313F70OtherMEDICARE NUMBER