Provider Demographics
NPI:1376793166
Name:AVICENNA LASER THERAPY CENTER, PC
Entity Type:Organization
Organization Name:AVICENNA LASER THERAPY CENTER, PC
Other - Org Name:TEMPLE PHYSICAL MEDICINE GROUP, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:TEMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-657-2282
Mailing Address - Street 1:8563 E SAN ALBERTO DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4345
Mailing Address - Country:US
Mailing Address - Phone:480-657-2282
Mailing Address - Fax:480-614-3378
Practice Address - Street 1:8563 E SAN ALBERTO DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4345
Practice Address - Country:US
Practice Address - Phone:480-657-2282
Practice Address - Fax:480-614-3378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4548111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty