Provider Demographics
NPI:1053465807
Name:MAXIM CHIROPRACTIC AND REHABILITATION CENTER PLLC
Entity Type:Organization
Organization Name:MAXIM CHIROPRACTIC AND REHABILITATION CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSSUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-222-5170
Mailing Address - Street 1:1830 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:480-222-5163
Practice Address - Street 1:1840 E WARNER RD
Practice Address - Street 2:SUITE 122
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-3437
Practice Address - Country:US
Practice Address - Phone:480-755-1718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0936660OtherBLUE CROSS BLUE SHIELD
AZAZ0931560OtherBLUE CROSS BLUE SHIELD
AZAZ0936660OtherBLUE CROSS BLUE SHIELD