Provider Demographics
NPI:1366625980
Name:PRESCOTT VALLEY DISC AND SPINE CENTER
Entity Type:Organization
Organization Name:PRESCOTT VALLEY DISC AND SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-632-1430
Mailing Address - Street 1:7485 E. 1ST ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314
Mailing Address - Country:US
Mailing Address - Phone:928-632-1430
Mailing Address - Fax:928-632-1434
Practice Address - Street 1:7485 E 1ST ST
Practice Address - Street 2:SUITE G
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2241
Practice Address - Country:US
Practice Address - Phone:928-632-1430
Practice Address - Fax:928-632-1434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7654111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ105254Medicare PIN