Provider Demographics
NPI:1932387511
Name:MOUNTAIN CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:MOUNTAIN CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:FLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:928-474-8417
Mailing Address - Street 1:411 S BEELINE HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4892
Mailing Address - Country:US
Mailing Address - Phone:928-474-8417
Mailing Address - Fax:928-474-8417
Practice Address - Street 1:411 S BEELINE HWY
Practice Address - Street 2:SUITE C
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4892
Practice Address - Country:US
Practice Address - Phone:928-474-8417
Practice Address - Fax:928-474-8417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDC3716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ120589OtherPTAN
AZ120589OtherPTAN