Provider Demographics
NPI:1356417711
Name:WHITE CRANE CLINIC, P.A.
Entity type:Organization
Organization Name:WHITE CRANE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:505-758-2700
Mailing Address - Street 1:1332 GUSDORF RD
Mailing Address - Street 2:STE. E
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6371
Mailing Address - Country:US
Mailing Address - Phone:505-758-2700
Mailing Address - Fax:505-758-2700
Practice Address - Street 1:1332 GUSDORF RD
Practice Address - Street 2:STE. E
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6371
Practice Address - Country:US
Practice Address - Phone:505-758-2700
Practice Address - Fax:505-758-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center