MEDICARE: PREFERRED CHIROPRACTIC TWELVE, PC

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

General Provider Information

NPI Number	:	1932156429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREFERRED CHIROPRACTIC TWELVE, PC

Provider Business Mailing Address
First Line	:	5024 S ASH AVE
Second Line	:	STE. 106
City	:	TEMPE
State	:	AZ
Zip	:	85282-6847
Country	:	US
Telephone Number	:	480-893-8600
Fax Number	:	480-756-0229

Provider Business Practice Location Address
First Line	:	111 E WACKER DR
Second Line	:	STE. 1210
City	:	CHICAGO
State	:	IL
Zip	:	60601-3713
Country	:	US
Telephone Number	:	312-819-0374
Fax Number	:

Authorized Official
Title or Position	:	VICE-PRESIDENT
Name	:	DOUGLAS H BLACK
Credential	:
Telephone Number	:	480-893-8600

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	08/22/2020

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