Healthcare Provider Details

I. General information

NPI: 1396945531
Provider Name (Legal Business Name): KEARNY LIFE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 ALDEN RD.
KEARNY AZ
85237
US

IV. Provider business mailing address

PO BOX 1149
KEARNY AZ
85237-1149
US

V. Phone/Fax

Practice location:
  • Phone: 520-363-7734
  • Fax: 520-363-7213
Mailing address:
  • Phone: 520-363-7734
  • Fax: 520-363-7213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number5499, 5517
License Number StateAZ

VIII. Authorized Official

Name: DR. GLENN KEITH AZZARI
Title or Position: CHIROPRACTOR/PARTNER OWNER
Credential: D.C.
Phone: 520-363-7734