Healthcare Provider Details

I. General information

NPI: 1326216391
Provider Name (Legal Business Name): ATLAS SPINE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E. MCKELLIPS RD. SUITE 106
MESA AZ
85203-2855
US

IV. Provider business mailing address

1919 E. MCKELLIPS RD. SUITE 106
MESA AZ
85203-2855
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-0302
  • Fax: 480-833-0904
Mailing address:
  • Phone: 480-833-0302
  • Fax: 480-833-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7548
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1472
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4477
License Number StateAZ

VIII. Authorized Official

Name: DR. DAN H FROERER
Title or Position: MANAGER
Credential: D.C.
Phone: 480-833-0302