1528256310 NPI number — QUALLS COMPREHENSIVE CHIROPRACTIC INC

Table of content: (NPI 1528256310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528256310 NPI number — QUALLS COMPREHENSIVE CHIROPRACTIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUALLS COMPREHENSIVE CHIROPRACTIC INC
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:
1528256310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12020 N 35TH AVE
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85029-3213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-862-9419
Provider Business Mailing Address Fax Number:
866-905-5721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12020 N 35TH AVE
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85029-3213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-862-9419
Provider Business Practice Location Address Fax Number:
866-905-5721
Provider Enumeration Date:
10/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
QUALLS
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
602-862-9419

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2030 , 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: AZ0938530 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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