Provider Demographics
NPI:1952587909
Name:ARIZONA SPINE AND HEALTH CENTER
Entity Type:Organization
Organization Name:ARIZONA SPINE AND HEALTH CENTER
Other - Org Name:AZ SPINE & HEALTH CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GALLARDO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:480-203-5632
Mailing Address - Street 1:4747 E ELLIOT RD
Mailing Address - Street 2:32
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-1627
Mailing Address - Country:US
Mailing Address - Phone:480-893-8700
Mailing Address - Fax:480-893-1300
Practice Address - Street 1:4747 E ELLIOT RD
Practice Address - Street 2:32
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-1627
Practice Address - Country:US
Practice Address - Phone:480-893-8700
Practice Address - Fax:480-893-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-20
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7890111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ121363Medicare PIN