Provider Demographics
NPI:1336368158
Name:KINGSWOOD PARKE FAMILY CHIROPRACTIC INC
Entity Type:Organization
Organization Name:KINGSWOOD PARKE FAMILY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:ENOUEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-556-4772
Mailing Address - Street 1:15508 W BELL RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2432
Mailing Address - Country:US
Mailing Address - Phone:623-556-4772
Mailing Address - Fax:623-556-2316
Practice Address - Street 1:15508 W BELL RD STE 105
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2432
Practice Address - Country:US
Practice Address - Phone:623-556-4772
Practice Address - Fax:623-556-2316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0241860OtherBLUE CROSS BLUE SHIELD
AZZDC5489Medicare ID - Type UnspecifiedMEDICARE NUMBER
AZU60552Medicare UPIN