Healthcare Provider Details

I. General information

NPI: 1609084128
Provider Name (Legal Business Name): SUMMIT CHIROPRACTIC AND WELLNESS CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 N 4TH ST SUITE 3
FLAGSTAFF AZ
86004-1812
US

IV. Provider business mailing address

2615 N 4TH ST SUITE 3
FLAGSTAFF AZ
86004-1812
US

V. Phone/Fax

Practice location:
  • Phone: 928-214-8969
  • Fax: 928-214-7405
Mailing address:
  • Phone: 928-214-8969
  • Fax: 928-214-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7149
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3836
License Number StateAZ

VIII. Authorized Official

Name: DR. MICHAEL S MARTIN
Title or Position: CHIROPRACTOR
Credential:
Phone: 928-214-8969