Provider Demographics
NPI:1215940614
Name:SUN VALLEY AFFILIATED BACK CENTER INC
Entity type:Organization
Organization Name:SUN VALLEY AFFILIATED BACK CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GRAUL
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:480-963-3608
Mailing Address - Street 1:2934 E HALE ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5592
Mailing Address - Country:US
Mailing Address - Phone:602-769-4982
Mailing Address - Fax:480-855-5756
Practice Address - Street 1:1534 E RAY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4429
Practice Address - Country:US
Practice Address - Phone:480-963-3608
Practice Address - Fax:480-855-5756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1086261QM2500X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP39180Medicare UPIN