Provider Demographics
NPI:1962575175
Name:WALL, LISE S (DC)
Entity type:Individual
Prefix:
First Name:LISE
Middle Name:S
Last Name:WALL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CALIENTE RD
Mailing Address - Street 2:STE 2A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9100
Mailing Address - Country:US
Mailing Address - Phone:505-466-1429
Mailing Address - Fax:505-466-1437
Practice Address - Street 1:5 CALIENTE RD
Practice Address - Street 2:STE 2A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-9100
Practice Address - Country:US
Practice Address - Phone:505-466-1429
Practice Address - Fax:505-466-1437
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM1683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMV11419Medicare UPIN
NM342707202Medicare PIN