1063522837 NPI number — AGAPE CHIROPRACTIC CORPORATION

Table of content: (NPI 1063522837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063522837 NPI number — AGAPE CHIROPRACTIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAPE CHIROPRACTIC CORPORATION
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:
Provider Other Organization Name Type Code:
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:
1063522837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 N BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRUTH OR CONSEQUENCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87901-2836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-894-9355
Provider Business Mailing Address Fax Number:
505-894-8588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 N BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRUTH OR CONSEQUENCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87901-2836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-894-9355
Provider Business Practice Location Address Fax Number:
505-894-8588
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROCK
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-740-3688

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1493 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: 1052 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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