Provider Demographics
NPI:1629261920
Name:CHIROCOMPLETE WELLNESS LLC
Entity Type:Organization
Organization Name:CHIROCOMPLETE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENR/CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-363-4005
Mailing Address - Street 1:15786 N HIDDEN VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4888
Mailing Address - Country:US
Mailing Address - Phone:623-363-4005
Mailing Address - Fax:623-889-7411
Practice Address - Street 1:15786 N HIDDEN VALLEY LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4888
Practice Address - Country:US
Practice Address - Phone:623-363-4005
Practice Address - Fax:623-889-7411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ116794Medicare UPIN