Provider Demographics
NPI:1720272172
Name:HEALTHSOURCE CHIROPRACTIC LLC ARROWHEAD
Entity Type:Organization
Organization Name:HEALTHSOURCE CHIROPRACTIC LLC ARROWHEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SRDICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-979-7100
Mailing Address - Street 1:8765 W. KELTON LANE SUITE 150
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3802
Mailing Address - Country:US
Mailing Address - Phone:623-979-7100
Mailing Address - Fax:623-979-3577
Practice Address - Street 1:8765 W KELTON LN STE 150
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5010
Practice Address - Country:US
Practice Address - Phone:626-979-7100
Practice Address - Fax:623-979-3577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDC5254111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1346320736OtherBLUE CROSS/ BLUE SHIELD
AZ1Z4643OtherHEALTHNET
AZP00219760OtherRAILROAD M/C
AZ1Z4643OtherHEALTHNET
AZ1346320736OtherBLUE CROSS/ BLUE SHIELD