Provider Demographics
NPI:1336528918
Name:DIAMONDBACK WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:DIAMONDBACK WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:T
Authorized Official - Last Name:OGORZALY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:505-242-1067
Mailing Address - Street 1:633 KINLEY AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1282
Mailing Address - Country:US
Mailing Address - Phone:505-242-1067
Mailing Address - Fax:
Practice Address - Street 1:633 KINLEY AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-242-1067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIAMONDBACK WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1000111N00000X
NM230171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty