Provider Demographics
NPI:1700033412
Name:60002 AVONDALE REHABILITATION CENTER
Entity Type:Organization
Organization Name:60002 AVONDALE REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GERAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-935-9920
Mailing Address - Street 1:PO BOX 2954
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-2954
Mailing Address - Country:US
Mailing Address - Phone:623-935-9920
Mailing Address - Fax:
Practice Address - Street 1:12409 W INDIAN SCHOOL RD
Practice Address - Street 2:B210
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-9502
Practice Address - Country:US
Practice Address - Phone:623-935-9920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-25
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7536111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty