Provider Demographics
NPI:1306195003
Name:FIFTH STREET CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:FIFTH STREET CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:BENTSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:520-747-2724
Mailing Address - Street 1:5602 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2449
Mailing Address - Country:US
Mailing Address - Phone:520-747-2724
Mailing Address - Fax:520-747-5845
Practice Address - Street 1:5602 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2449
Practice Address - Country:US
Practice Address - Phone:520-747-2724
Practice Address - Fax:520-747-5845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3764111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1871597237Medicare PIN