Provider Demographics
NPI:1295937589
Name:BARDWELL, GEORGE LYNN (DC)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:LYNN
Last Name:BARDWELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 N GRAND CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMS
Mailing Address - State:AZ
Mailing Address - Zip Code:86046-2016
Mailing Address - Country:US
Mailing Address - Phone:928-635-9115
Mailing Address - Fax:928-635-9115
Practice Address - Street 1:706 N GRAND CANYON BLVD.
Practice Address - Street 2:
Practice Address - City:WILLIAMS
Practice Address - State:AZ
Practice Address - Zip Code:86046-2200
Practice Address - Country:US
Practice Address - Phone:928-635-9115
Practice Address - Fax:928-635-9115
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ898111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860363015OtherFED I D #
AZZ20750Medicare ID - Type Unspecified