Provider Demographics
NPI:1114008034
Name:NORTHERN ARIZONA SPINAL CARE, PLLC
Entity Type:Organization
Organization Name:NORTHERN ARIZONA SPINAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR OG CHIROPRACTIC
Authorized Official - Prefix:MR
Authorized Official - First Name:KAI
Authorized Official - Middle Name:M G
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-226-9195
Mailing Address - Street 1:2225 E 7TH AVE
Mailing Address - Street 2:SUITE A AND B
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-226-9195
Mailing Address - Fax:928-226-9167
Practice Address - Street 1:2225 E 7TH AVE
Practice Address - Street 2:SUITE A AND B
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-226-9195
Practice Address - Fax:928-226-9167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6006111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ60249Medicare ID - Type Unspecified