Provider Demographics
NPI:1336192871
Name:KACHINA HEALING CENTER, LLC
Entity Type:Organization
Organization Name:KACHINA HEALING CENTER, LLC
Other - Org Name:KACHINA HEALING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MULBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC-
Authorized Official - Phone:928-772-4500
Mailing Address - Street 1:8363 E FLORENTINE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-4971
Mailing Address - Country:US
Mailing Address - Phone:928-772-4500
Mailing Address - Fax:928-772-2622
Practice Address - Street 1:8363 E FLORENTINE RD
Practice Address - Street 2:SUITE C
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-4971
Practice Address - Country:US
Practice Address - Phone:928-772-4500
Practice Address - Fax:928-772-2622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5361111N00000X
CADC 23923111N00000X
AZ5361 - 386171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ74253Medicare ID - Type UnspecifiedMEDICARE GROUP