Provider Demographics
NPI:1720207210
Name:VICENA CHIROPRACTIC SC
Entity Type:Organization
Organization Name:VICENA CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:REMALIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-854-2222
Mailing Address - Street 1:6344 E BROADWAY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1634
Mailing Address - Country:US
Mailing Address - Phone:480-854-2222
Mailing Address - Fax:480-807-3781
Practice Address - Street 1:6344 E BROADWAY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1634
Practice Address - Country:US
Practice Address - Phone:480-854-2222
Practice Address - Fax:480-807-3781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5429111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z4184OtherHEALTHNET
AZAZ0247740OtherBLUE CROSS BLUE SHIELD AZ
AZZ81866Medicare ID - Type Unspecified
AZ1Z4184OtherHEALTHNET