MEDICARE: RENAISSANCE CHIROPRACTIC P C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5145	AZ

General Provider Information

NPI Number	:	1003096363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE CHIROPRACTIC P C

Provider Business Mailing Address
First Line	:	112 N CENTRAL AVE
Second Line	:	A2
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2309
Country	:	US
Telephone Number	:	602-712-9444
Fax Number	:	602-258-7844

Provider Business Practice Location Address
First Line	:	112 N CENTRAL AVE
Second Line	:	A2
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2309
Country	:	US
Telephone Number	:	602-712-9444
Fax Number	:	602-258-7844

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	DR. REBECCA DAWN CARLSON
Credential	:	D.C.
Telephone Number	:	602-712-9444

Provider Enumeration Date	:	11/05/2007
Last Update Date	:	11/05/2007

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