Provider Demographics
NPI: | 1033494588 |
---|---|
Name: | SOUTH MOUNTAIN CHIROPRACTIC |
Entity Type: | Organization |
Organization Name: | SOUTH MOUNTAIN CHIROPRACTIC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DONALD |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | BERNARD |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 480-759-8566 |
Mailing Address - Street 1: | 5505 W CHANDLER BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | CHANDLER |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85226-3683 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 480-759-8566 |
Mailing Address - Fax: | 480-704-2448 |
Practice Address - Street 1: | 1450 W. GUADALUPE RD #120 |
Practice Address - Street 2: | |
Practice Address - City: | GILBERT |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85233 |
Practice Address - Country: | US |
Practice Address - Phone: | 480-926-7800 |
Practice Address - Fax: | 480-926-2260 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-10-17 |
Last Update Date: | 2011-10-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 5458 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |