Basic Information
| Provider Information | |||||||||
| NPI: | 1043469182 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLENDALE SPRINGS CHIROPRACTIC AND REHAB, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AFC CHIROPRACTIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1839 S ALMA SCHOOL RD | ||||||||
| Address2: | SUITE 354 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807262287 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2826 W NORTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850516626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028410200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2008 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOCK | ||||||||
| AuthorizedOfficialFirstName: | JOSH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4807262287 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | Z137331 | 01 | AZ | MEDICARE PTAN | OTHER |