Provider Demographics
NPI:1912035965
Name:DESERT RIDGE SPINE, INC
Entity Type:Organization
Organization Name:DESERT RIDGE SPINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:OHARA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-832-3318
Mailing Address - Street 1:3035 S ELLSWORTH RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2160
Mailing Address - Country:US
Mailing Address - Phone:480-832-3318
Mailing Address - Fax:480-621-7208
Practice Address - Street 1:3035 S ELLSWORTH RD
Practice Address - Street 2:SUITE 109
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2160
Practice Address - Country:US
Practice Address - Phone:480-832-3318
Practice Address - Fax:480-621-7208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDC4914111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0236730OtherBLUE CROSS
AZU25671Medicare UPIN
AZAZ0236730OtherBLUE CROSS