1700835303 NPI number — SURPRISE CHIROPRACTIC GROUP, L.L.C.

Table of content: OCTAVIA CAMILLE AMERSON LMSW (NPI 1437524634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700835303 NPI number — SURPRISE CHIROPRACTIC GROUP, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURPRISE CHIROPRACTIC GROUP, L.L.C.
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:
1700835303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14545 W GRAND AVE
Provider Second Line Business Mailing Address:
SUITE # A106
Provider Business Mailing Address City Name:
SURPRISE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85374-7278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-544-9111
Provider Business Mailing Address Fax Number:
623-544-9333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14545 W GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE # A106
Provider Business Practice Location Address City Name:
SURPRISE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85374-7278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-544-9111
Provider Business Practice Location Address Fax Number:
623-544-9333
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VERLOOP
Authorized Official First Name:
LOUIS
Authorized Official Middle Name:
VICTOR
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
623-544-9111

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  7337 , 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)





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