Provider Demographics
NPI:1821363342
Name:ARIZONA CENTER FOR FUNTIONAL MEDICINE
Entity Type:Organization
Organization Name:ARIZONA CENTER FOR FUNTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FIERRO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-485-8000
Mailing Address - Street 1:16421 N TATUM BLVD
Mailing Address - Street 2:SUITE, 203
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3454
Mailing Address - Country:US
Mailing Address - Phone:602-485-8000
Mailing Address - Fax:602-485-8010
Practice Address - Street 1:16421 N TATUM BLVD
Practice Address - Street 2:SUITE, 203
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3454
Practice Address - Country:US
Practice Address - Phone:602-485-8000
Practice Address - Fax:602-485-8010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU58747Medicare UPIN