Provider Demographics
NPI:1851317259
Name:DR. SERGIO NINO LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:DR. SERGIO NINO LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:NINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-995-4336
Mailing Address - Street 1:2333 W NORTHERN AVE STE 1B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-9348
Mailing Address - Country:US
Mailing Address - Phone:602-995-4336
Mailing Address - Fax:602-995-4340
Practice Address - Street 1:2333 W NORTHERN AVE STE 1B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-9348
Practice Address - Country:US
Practice Address - Phone:602-995-4336
Practice Address - Fax:602-995-4340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8019111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU88125Medicare UPIN
AZ68066Medicare ID - Type UnspecifiedMEDICARE PROVIDER #