Provider Demographics
NPI:1235208265
Name:COUNTRY CLUB CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:COUNTRY CLUB CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER PRACTICING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:SANDERS
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-834-1700
Mailing Address - Street 1:1140 S COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 111-B
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4649
Mailing Address - Country:US
Mailing Address - Phone:480-834-1700
Mailing Address - Fax:480-834-1200
Practice Address - Street 1:1140 S COUNTRY CLUB DR
Practice Address - Street 2:SUITE 111-B
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4649
Practice Address - Country:US
Practice Address - Phone:480-834-1700
Practice Address - Fax:480-834-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5551111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU67375Medicare UPIN