1265802086 NPI number — POWELL CHIROPRACTIC HEALTH CENTER

Table of content: (NPI 1265802086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265802086 NPI number — POWELL CHIROPRACTIC HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POWELL CHIROPRACTIC HEALTH CENTER
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:
1265802086
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7575 W PEORIA AVE
Provider Second Line Business Mailing Address:
SUITE A-106
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85345-5873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-873-4444
Provider Business Mailing Address Fax Number:
623-979-8515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7575 W PEORIA AVE
Provider Second Line Business Practice Location Address:
SUITE A-106
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85345-5873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-873-4444
Provider Business Practice Location Address Fax Number:
623-979-8515
Provider Enumeration Date:
10/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
TYLER
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
623-873-4444

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4767 , 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: ZDC4767 . This is a "PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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