Basic Information
Provider Information | |||||||||
NPI: | 1396975108 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH PHOENIX CHIROPRACTIC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9907 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850680907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6237803751 | ||||||||
FaxNumber: | 6237803752 | ||||||||
Practice Location | |||||||||
Address1: | 19841 N 27TH AVE | ||||||||
Address2: | SUITE 301 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850274003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6237803751 | ||||||||
FaxNumber: | 6237803752 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2009 | ||||||||
LastUpdateDate: | 10/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GROVER | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6237803751 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   |
No ID Information.