Provider Demographics
NPI:1558493932
Name:MY CHIROPRACTOR OF PAYSON LLC
Entity Type:Organization
Organization Name:MY CHIROPRACTOR OF PAYSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-474-0442
Mailing Address - Street 1:405 S BEELINE HWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4800
Mailing Address - Country:US
Mailing Address - Phone:928-474-0442
Mailing Address - Fax:
Practice Address - Street 1:405 S BEELINE HWY
Practice Address - Street 2:SUITE D
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4800
Practice Address - Country:US
Practice Address - Phone:928-474-0442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4644111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDC4644Medicare ID - Type Unspecified