Provider Demographics
NPI:1326362807
Name:TRIAD CHIROPRACTIC & REHABILITATION CLINICS, LLC
Entity Type:Organization
Organization Name:TRIAD CHIROPRACTIC & REHABILITATION CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-413-0586
Mailing Address - Street 1:2745 S ALMA SCHOOL RD STE 2
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-4405
Mailing Address - Country:US
Mailing Address - Phone:480-413-0586
Mailing Address - Fax:480-730-0487
Practice Address - Street 1:4515 S. MCCLINTOCK DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7382
Practice Address - Country:US
Practice Address - Phone:480-413-0586
Practice Address - Fax:480-413-0586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5837111NI0013X
AZAZ5837111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ137081Medicare PIN