Healthcare Provider Details

I. General information

NPI: 1437712528
Provider Name (Legal Business Name): AMMON ALLEN OPIE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S MESA DR STE 4
MESA AZ
85210-1458
US

IV. Provider business mailing address

110 S MESA DR STE 4
MESA AZ
85210-1458
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-8863
  • Fax: 480-464-5516
Mailing address:
  • Phone: 480-833-8863
  • Fax: 480-464-5516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8802
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5373
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: