Provider Demographics
NPI:1700835303
Name:SURPRISE CHIROPRACTIC GROUP, L.L.C.
Entity Type:Organization
Organization Name:SURPRISE CHIROPRACTIC GROUP, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:VERLOOP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-544-9111
Mailing Address - Street 1:14545 W GRAND AVE
Mailing Address - Street 2:SUITE # A106
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7278
Mailing Address - Country:US
Mailing Address - Phone:623-544-9111
Mailing Address - Fax:623-544-9333
Practice Address - Street 1:14545 W GRAND AVE
Practice Address - Street 2:SUITE # A106
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7278
Practice Address - Country:US
Practice Address - Phone:623-544-9111
Practice Address - Fax:623-544-9333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7337111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ76980Medicare ID - Type UnspecifiedMY INDIVIDUAL #
AZU69642Medicare UPIN
AZZ76979Medicare ID - Type UnspecifiedLLC GROUP #