1619156494 NPI number — BRUCE A WEARY DC LTD

Table of content: (NPI 1619156494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619156494 NPI number — BRUCE A WEARY DC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUCE A WEARY DC LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WEARY CHIROPRACTIC CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619156494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
980 WILLOW CREEK ROAD
Provider Second Line Business Mailing Address:
104
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-778-2227
Provider Business Mailing Address Fax Number:
928-771-9159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
980 WILLOW CREEK ROAD
Provider Second Line Business Practice Location Address:
104
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-778-2227
Provider Business Practice Location Address Fax Number:
928-771-9159
Provider Enumeration Date:
10/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WEARY
Authorized Official First Name:
DAYNA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
928-778-2227

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  AZ3936 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)