Basic Information
| Provider Information | |||||||||
| NPI: | 1205060647 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERICAN FAMILY CHIROPRACTIC & REHAB OF PEORIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1839 S ALMA SCHOOL RD | ||||||||
| Address2: | STE 354 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103023 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15256 N 75TH AVE | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807262287 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2009 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | BOCK | ||||||||
| AuthorizedOfficialFirstName: | JOSH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4807262287 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.