Provider Demographics
NPI:1811021439
Name:SUN VALLEY CHIROPRACTIC AND WELLNESS
Entity Type:Organization
Organization Name:SUN VALLEY CHIROPRACTIC AND WELLNESS
Other - Org Name:RK CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WORTH
Authorized Official - Last Name:MANKTELOW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-892-5631
Mailing Address - Street 1:1111 N GILBERT RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2313
Mailing Address - Country:US
Mailing Address - Phone:480-892-5631
Mailing Address - Fax:480-892-5649
Practice Address - Street 1:1111 N GILBERT RD
Practice Address - Street 2:SUITE 115
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2313
Practice Address - Country:US
Practice Address - Phone:480-892-5631
Practice Address - Fax:480-892-5649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ114447Medicare PIN