Provider Demographics
NPI:1720279854
Name:ARIZONA DISC AND SPINE CENTER LLC
Entity Type:Organization
Organization Name:ARIZONA DISC AND SPINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-787-9511
Mailing Address - Street 1:3305 E GREENWAY RD
Mailing Address - Street 2:#7
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4509
Mailing Address - Country:US
Mailing Address - Phone:602-787-9511
Mailing Address - Fax:
Practice Address - Street 1:3305 E GREENWAY RD
Practice Address - Street 2:#7
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4509
Practice Address - Country:US
Practice Address - Phone:602-787-9511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5541111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ116238Medicare PIN
AZZ116237Medicare PIN