Provider Demographics
NPI:1013097203
Name:CACTUS CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CACTUS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-878-9388
Mailing Address - Street 1:7440 W CACTUS RD
Mailing Address - Street 2:A19
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-9535
Mailing Address - Country:US
Mailing Address - Phone:623-878-9388
Mailing Address - Fax:623-878-9114
Practice Address - Street 1:7440 W CACTUS RD
Practice Address - Street 2:A19
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-9535
Practice Address - Country:US
Practice Address - Phone:623-878-9388
Practice Address - Fax:623-878-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4094111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ84650Medicare PIN