Provider Demographics
NPI:1700061355
Name:PHOENIX LIFE CENTER INC
Entity Type:Organization
Organization Name:PHOENIX LIFE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIANA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-973-6609
Mailing Address - Street 1:3650 W BETHANY HOME RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-1967
Mailing Address - Country:US
Mailing Address - Phone:602-973-6609
Mailing Address - Fax:602-973-0067
Practice Address - Street 1:3650 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-1967
Practice Address - Country:US
Practice Address - Phone:602-973-6609
Practice Address - Fax:602-973-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ875111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCHHSMedicare PIN