Provider Demographics
NPI:1073667846
Name:MAXIM CHIROPRACTIC TWO
Entity Type:Organization
Organization Name:MAXIM CHIROPRACTIC TWO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
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:480-635-1718
Mailing Address - Fax:480-635-1719
Practice Address - Street 1:1337 S GILBERT RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6073
Practice Address - Country:US
Practice Address - Phone:480-635-1718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0447360OtherBLUE CROSS BLUE SHIELD