Provider Demographics
NPI:1205187689
Name:WIDMAIER CHIROPRACTIC
Entity Type:Organization
Organization Name:WIDMAIER CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:S
Authorized Official - Last Name:WIDMAIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-954-6200
Mailing Address - Street 1:5080 N 40TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2158
Mailing Address - Country:US
Mailing Address - Phone:602-954-6200
Mailing Address - Fax:602-956-1582
Practice Address - Street 1:5080 N 40TH ST STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2158
Practice Address - Country:US
Practice Address - Phone:602-954-6200
Practice Address - Fax:602-956-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4220261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTAX ID