Provider Demographics
NPI:1811175482
Name:OUTBACK CHIROPRACTIC LLC
Entity type:Organization
Organization Name:OUTBACK CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANNY
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-337-3125
Mailing Address - Street 1:PO BOX 2578
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:AZ
Mailing Address - Zip Code:85936-2578
Mailing Address - Country:US
Mailing Address - Phone:928-337-3125
Mailing Address - Fax:928-337-3291
Practice Address - Street 1:1200 W. CLEVELAND
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:AZ
Practice Address - Zip Code:85936-1200
Practice Address - Country:US
Practice Address - Phone:928-337-3125
Practice Address - Fax:928-337-3291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ841595Medicaid
AZ841595Medicaid
AZZ78280Medicare PIN