Provider Demographics
NPI:1578831327
Name:CHAVIRA, VICENTE (DC, ATC)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:
Last Name:CHAVIRA
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 E. CHOLLA ST.
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-1413
Mailing Address - Country:US
Mailing Address - Phone:480-888-5555
Mailing Address - Fax:
Practice Address - Street 1:10 E. RUTH AVE.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3032
Practice Address - Country:US
Practice Address - Phone:480-888-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-0012612255A2300X
AZ8328111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer