Provider Demographics
NPI:1417148354
Name:DESERT VALLEY CHIROPRACTIC
Entity Type:Organization
Organization Name:DESERT VALLEY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLARUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DC,
Authorized Official - Phone:775-727-0888
Mailing Address - Street 1:2340 E CALVADA BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-5821
Mailing Address - Country:US
Mailing Address - Phone:775-727-0888
Mailing Address - Fax:775-727-2362
Practice Address - Street 1:2340 E CALVADA BLVD STE 3
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5821
Practice Address - Country:US
Practice Address - Phone:775-727-0888
Practice Address - Fax:775-727-2362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB-0613111N00000X
NVB-0871111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVU57529Medicare UPIN