Basic Information
Provider Information | |||||||||
NPI: | 1013431253 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MADDOX | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1839 S ALMA SCHOOL RD STE 354 | ||||||||
Address2: |   | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852103028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4807262287 | ||||||||
FaxNumber: | 8883169272 | ||||||||
Practice Location | |||||||||
Address1: | 15256 N 75TH AVE STE 360 | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | AZ | ||||||||
PostalCode: | 853814761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6234862424 | ||||||||
FaxNumber: | 6234864324 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2017 | ||||||||
LastUpdateDate: | 07/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 7855 | CO | N |   | Chiropractic Providers | Chiropractor |   | 111N00000X | 2017015756 | MO | N |   | Chiropractic Providers | Chiropractor |   | 111N00000X | 8942 | AZ | Y |   | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 2017015756 | 01 | MO | MISSOURI STATE BOARD OF CHIROPRACTIC EXAMINERS | OTHER |