Provider Demographics
NPI:1972865939
Name:BEELINE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:BEELINE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JON
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-474-5555
Mailing Address - Street 1:414 S BEELINE HWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4884
Mailing Address - Country:US
Mailing Address - Phone:928-474-5555
Mailing Address - Fax:928-474-3707
Practice Address - Street 1:414 S BEELINE HWY
Practice Address - Street 2:SUITE 6
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4884
Practice Address - Country:US
Practice Address - Phone:928-474-5555
Practice Address - Fax:928-474-3707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3547111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ62249Medicare UPIN