Provider Demographics
NPI:1942481379
Name:CLOUSE CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:CLOUSE CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:CLOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-834-9000
Mailing Address - Street 1:437 S GILBERT RD STE 14
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-2866
Mailing Address - Country:US
Mailing Address - Phone:480-834-9000
Mailing Address - Fax:480-834-1880
Practice Address - Street 1:437 S GILBERT RD STE 14
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-2866
Practice Address - Country:US
Practice Address - Phone:480-834-9000
Practice Address - Fax:480-834-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4560261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0943720OtherBC/BS
AZAZ0943720OtherBC/BS
AZZ81526Medicare PIN