Provider Demographics
NPI:1306850953
Name:GC GROVER BS DC PC
Entity Type:Organization
Organization Name:GC GROVER BS DC PC
Other - Org Name:MOON VALLEY CHIROPRACTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-298-0292
Mailing Address - Street 1:15420 NORTH 7TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022
Mailing Address - Country:US
Mailing Address - Phone:602-298-0292
Mailing Address - Fax:602-298-6961
Practice Address - Street 1:15420 NORTH 7TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022
Practice Address - Country:US
Practice Address - Phone:602-298-0292
Practice Address - Fax:602-298-6961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0249810OtherBCBS OF AZ PROVIDER #
AZT41671Medicare UPIN