Provider Demographics
NPI:1346422086
Name:LAVENDER, IRA KEITH (DC)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:KEITH
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 E BASELINE RD STE 126
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2475
Mailing Address - Country:US
Mailing Address - Phone:480-325-6977
Mailing Address - Fax:602-296-0487
Practice Address - Street 1:2915 E BASELINE RD STE 126
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2475
Practice Address - Country:US
Practice Address - Phone:480-325-6977
Practice Address - Fax:602-296-0487
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6015111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ63087OtherMEDICARE GROUP
AZ1669486908OtherMEDICARE GROUP NPI
AZAZ0932280OtherBLUE CROSS BLUE SHIELD
AZ63087OtherMEDICARE GROUP
AZU77811Medicare UPIN