Provider Demographics
NPI:1396945531
Name:KEARNY LIFE CENTER, LLC
Entity type:Organization
Organization Name:KEARNY LIFE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/PARTNER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:AZZARI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:520-363-7734
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:AZ
Mailing Address - Zip Code:85237-1149
Mailing Address - Country:US
Mailing Address - Phone:520-363-7734
Mailing Address - Fax:520-363-7213
Practice Address - Street 1:384 ALDEN RD.
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:AZ
Practice Address - Zip Code:85237
Practice Address - Country:US
Practice Address - Phone:520-363-7734
Practice Address - Fax:520-363-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5499, 5517111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ 0935250OtherBLUE CROSS BLUE SHIELD
AZ68700Medicare UPIN