Provider Demographics
NPI:1417006602
Name:NATURAL WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:NATURAL WELLNESS CENTER LLC
Other - Org Name:SUNRISE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PERUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-992-6200
Mailing Address - Street 1:11030 N TATUM BLVD
Mailing Address - Street 2:101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6073
Mailing Address - Country:US
Mailing Address - Phone:602-992-6200
Mailing Address - Fax:602-992-6206
Practice Address - Street 1:11030 N TATUM BLVD
Practice Address - Street 2:101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6073
Practice Address - Country:US
Practice Address - Phone:602-992-6200
Practice Address - Fax:602-992-6200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5635111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ29545Medicare ID - Type Unspecified