Provider Demographics
NPI:1114385457
Name:ARIZONA SPORTS CLINIC LLC
Entity Type:Organization
Organization Name:ARIZONA SPORTS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:MAROSTICA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-906-6164
Mailing Address - Street 1:5735 E MCKELLIPS RD
Mailing Address - Street 2:SUITE B-106
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-2875
Mailing Address - Country:US
Mailing Address - Phone:602-668-8109
Mailing Address - Fax:
Practice Address - Street 1:5735 E MCKELLIPS RD
Practice Address - Street 2:SUITE B-106
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2875
Practice Address - Country:US
Practice Address - Phone:602-668-8109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty