Provider Demographics
NPI:1962651000
Name:SAN TAN MOUNTAIN CHIROPRACTIC AND REHAB, LLC
Entity Type:Organization
Organization Name:SAN TAN MOUNTAIN CHIROPRACTIC AND REHAB, LLC
Other - Org Name:AFC CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-882-2222
Mailing Address - Street 1:1839 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 354
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3023
Mailing Address - Country:US
Mailing Address - Phone:480-726-2287
Mailing Address - Fax:
Practice Address - Street 1:270 E HUNT HWY STE A-2
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-4962
Practice Address - Country:US
Practice Address - Phone:480-882-2222
Practice Address - Fax:480-882-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ136595OtherMEDICARE PTAN