Provider Demographics
NPI:1144226747
Name:AVONDALE ACCIDENT & PAIN CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:AVONDALE ACCIDENT & PAIN CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:FERNANDEZ
Authorized Official - Last Name:CUNANAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:622-936-6111
Mailing Address - Street 1:11335 W BUCKEYE RD
Mailing Address - Street 2:STE C104
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-6814
Mailing Address - Country:US
Mailing Address - Phone:623-936-6111
Mailing Address - Fax:623-936-1629
Practice Address - Street 1:11335 W BUCKEYE RD
Practice Address - Street 2:STE C104
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-6814
Practice Address - Country:US
Practice Address - Phone:623-936-6111
Practice Address - Fax:623-936-1629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ7287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V01266Medicare UPIN
83704Medicare ID - Type Unspecified