Provider Demographics
NPI:1013310085
Name:ADVANCED CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:ADVANCED CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:QUALLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:505-334-5004
Mailing Address - Street 1:1415 W AZTEC BLVD
Mailing Address - Street 2:STE 4
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-1868
Mailing Address - Country:US
Mailing Address - Phone:505-334-5004
Mailing Address - Fax:505-334-8077
Practice Address - Street 1:1415 W AZTEC BLVD
Practice Address - Street 2:STE 4
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1868
Practice Address - Country:US
Practice Address - Phone:505-334-5004
Practice Address - Fax:505-334-8077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2109111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty