Provider Demographics
NPI:1003096363
Name:RENAISSANCE CHIROPRACTIC P C
Entity Type:Organization
Organization Name:RENAISSANCE CHIROPRACTIC P C
Other - Org Name:RENAISSANCE CHIROPRACTIC & BODYWORK
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-712-9444
Mailing Address - Street 1:112 N CENTRAL AVE
Mailing Address - Street 2:A2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-2309
Mailing Address - Country:US
Mailing Address - Phone:602-712-9444
Mailing Address - Fax:602-258-7844
Practice Address - Street 1:112 N CENTRAL AVE
Practice Address - Street 2:A2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2309
Practice Address - Country:US
Practice Address - Phone:602-712-9444
Practice Address - Fax:602-258-7844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5145111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty