Healthcare Provider Details

I. General information

NPI: 1124026307
Provider Name (Legal Business Name): TRACY B PERUCH DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6770 W DEER VALLEY RD #B102
GLENDALE AZ
85310-5956
US

IV. Provider business mailing address

6770 W DEER VALLEY RD #B102
GLENDALE AZ
85310-5956
US

V. Phone/Fax

Practice location:
  • Phone: 623-362-1950
  • Fax: 623-572-2741
Mailing address:
  • Phone: 623-362-1950
  • Fax: 623-572-2741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5710
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number09-1105
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: