Provider Demographics
NPI:1376601039
Name:MOHAVE CHIROPRACTIC CARE LLC
Entity Type:Organization
Organization Name:MOHAVE CHIROPRACTIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-763-9225
Mailing Address - Street 1:PO BOX 22698
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86439-2698
Mailing Address - Country:US
Mailing Address - Phone:928-763-9225
Mailing Address - Fax:928-763-9224
Practice Address - Street 1:1708 EL CAZADOR
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7955
Practice Address - Country:US
Practice Address - Phone:928-763-9225
Practice Address - Fax:928-763-9224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7139111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP0155410OtherBLUE CROSS BLUE SHIELD
AZ786080Medicaid
AZP00100146OtherRAILROAD MEDICARE
AZU91623Medicare UPIN
AZ786080Medicaid