Provider Demographics
NPI:1326393927
Name:PROFORMA HEALTH PLLC
Entity Type:Organization
Organization Name:PROFORMA HEALTH PLLC
Other - Org Name:MUNDERLOH CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MUNDERLOH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-556-0707
Mailing Address - Street 1:1501 S YALE ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7304
Mailing Address - Country:US
Mailing Address - Phone:928-556-0707
Mailing Address - Fax:928-779-2223
Practice Address - Street 1:1501 S YALE ST
Practice Address - Street 2:SUITE 250
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7304
Practice Address - Country:US
Practice Address - Phone:928-556-0707
Practice Address - Fax:928-779-2223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNDERLOH HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1104883164OtherPROVIDER NPI
AZ5935OtherCHIROPRACTIC LICENSE
AZU81754Medicare UPIN
AZZ79285Medicare PIN