Provider Demographics
NPI:1700926284
Name:ADVANCED SPORTS CHIROPRACTIC AND REHABILITATION CLINIC PC
Entity Type:Organization
Organization Name:ADVANCED SPORTS CHIROPRACTIC AND REHABILITATION CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:XANTHOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-264-4040
Mailing Address - Street 1:5727 N 7TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5817
Mailing Address - Country:US
Mailing Address - Phone:602-264-4040
Mailing Address - Fax:602-264-3433
Practice Address - Street 1:5727 N 7TH ST STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5817
Practice Address - Country:US
Practice Address - Phone:602-264-4040
Practice Address - Fax:602-264-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5470111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZDC5470Medicare ID - Type Unspecified
AZU6190Medicare UPIN