Provider Demographics
NPI:1821276742
Name:DR CHARLES BOAG PC
Entity Type:Organization
Organization Name:DR CHARLES BOAG PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRIXNER
Authorized Official - Last Name:BOAG
Authorized Official - Suffix:JR
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:602-269-5717
Mailing Address - Street 1:4515 W INDIAN SCHOOL RD
Mailing Address - Street 2:BOAG CHIROPRACTIC
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-2820
Mailing Address - Country:US
Mailing Address - Phone:602-269-5717
Mailing Address - Fax:602-269-5718
Practice Address - Street 1:4515 W INDIAN SCHOOL RD
Practice Address - Street 2:BOAG CHIROPRACTIC
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-2820
Practice Address - Country:US
Practice Address - Phone:602-269-5717
Practice Address - Fax:602-269-5718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ756111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
756OtherARIZONA CHIROPRACTICE LIC
1C526804797OtherMEDICARE LEGACY