Provider Demographics
NPI:1144403239
Name:FULLY WIRED INC
Entity Type:Organization
Organization Name:FULLY WIRED INC
Other - Org Name:THE BACK ALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DARL
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:SHIPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:520-877-2666
Mailing Address - Street 1:10515 N ORACLE RD
Mailing Address - Street 2:SUITE 167
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-9377
Mailing Address - Country:US
Mailing Address - Phone:520-877-2666
Mailing Address - Fax:520-877-9183
Practice Address - Street 1:10515 N ORACLE RD
Practice Address - Street 2:SUITE 167
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-9377
Practice Address - Country:US
Practice Address - Phone:520-877-2666
Practice Address - Fax:520-877-9183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4277261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ73756Medicare PIN