Provider Demographics
NPI:1396830816
Name:SURPRISE CROSSING CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:SURPRISE CROSSING CHIROPRACTIC, LLC
Other - Org Name:SURPRISE CROSSING CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-584-7756
Mailing Address - Street 1:13794 W. WADDELL RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379
Mailing Address - Country:US
Mailing Address - Phone:623-584-7756
Mailing Address - Fax:623-584-2682
Practice Address - Street 1:13794 W. WADDELL RD
Practice Address - Street 2:SUITE 205
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379
Practice Address - Country:US
Practice Address - Phone:623-584-7756
Practice Address - Fax:623-584-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5947111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106695Medicare ID - Type Unspecified