1306850953 NPI number — GC GROVER BS DC PC

Table of content: (NPI 1306850953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306850953 NPI number — GC GROVER BS DC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GC GROVER BS DC PC
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:
MOON VALLEY CHIROPRACTIC
Provider Other Organization Name Type Code:
5
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:
1306850953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15420 NORTH 7TH ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-298-0292
Provider Business Mailing Address Fax Number:
602-298-6961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15420 NORTH 7TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-298-0292
Provider Business Practice Location Address Fax Number:
602-298-6961
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROVER
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
602-298-0292

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3782 , 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)

  • Identifier: AZ0249810 . This is a "BCBS OF AZ PROVIDER #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com