Provider Demographics
NPI:1992851489
Name:BRET R STALEY CHIROPRACTIC LTD
Entity Type:Organization
Organization Name:BRET R STALEY CHIROPRACTIC LTD
Other - Org Name:MOAPA VALLEY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES SEC TREAS
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:R
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:702-397-2273
Mailing Address - Street 1:PO BOX 1350
Mailing Address - Street 2:
Mailing Address - City:OVERTON
Mailing Address - State:NV
Mailing Address - Zip Code:89040-1350
Mailing Address - Country:US
Mailing Address - Phone:702-397-2273
Mailing Address - Fax:702-397-2705
Practice Address - Street 1:1170 N MOAPA VALLEY BLVD
Practice Address - Street 2:STE C
Practice Address - City:OVERTON
Practice Address - State:NV
Practice Address - Zip Code:89040-1350
Practice Address - Country:US
Practice Address - Phone:702-397-2273
Practice Address - Fax:702-397-2705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB506111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U33656Medicare UPIN
NVVDC506AMedicare PIN