Provider Demographics
NPI:1669427233
Name:QUACKENBUSH, JOHN Q (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:Q
Last Name:QUACKENBUSH
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 1:42104 N VENTURE DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3823
Mailing Address - Country:US
Mailing Address - Phone:623-551-9100
Mailing Address - Fax:623-551-9103
Practice Address - Street 1:42104 N VENTURE DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3823
Practice Address - Country:US
Practice Address - Phone:623-551-9100
Practice Address - Fax:623-551-9103
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3034111N00000X
AZ7143111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T26587Medicare UPIN
COC811754Medicare PIN