Provider Demographics
NPI:1447397336
Name:RETAIL AUTOMATION USA LLC
Entity Type:Organization
Organization Name:RETAIL AUTOMATION USA LLC
Other - Org Name:MUNDERLOH CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-556-0707
Mailing Address - Street 1:1501 S YALE ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7304
Mailing Address - Country:US
Mailing Address - Phone:928-556-0707
Mailing Address - Fax:928-779-2223
Practice Address - Street 1:1501 S YALE ST
Practice Address - Street 2:SUITE 250
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7304
Practice Address - Country:US
Practice Address - Phone:928-556-0707
Practice Address - Fax:928-779-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5935111N00000X
AZ1058111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5935OtherCHIROPRACTIC LICENCE
AZAZ09441160OtherBCBS AZ NUMBER
AZ1104883164OtherPROVIDER NPI
AZU81754Medicare UPIN
AZ5935OtherCHIROPRACTIC LICENCE