Healthcare Provider Details

I. General information

NPI: 1164951208
Provider Name (Legal Business Name): AZ LIFESTYLE CHIROPRACTIC CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14155 N 83RD AVE STE 102
PEORIA AZ
85381-5640
US

IV. Provider business mailing address

14155 N 83RD AVE STE 102
PEORIA AZ
85381-5640
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-0475
  • Fax: 623-878-0640
Mailing address:
  • Phone: 623-878-0475
  • Fax: 623-878-0640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC5016
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC5016
License Number StateAZ

VIII. Authorized Official

Name: MS. ROBIN MCMAHAN
Title or Position: MANAGER
Credential:
Phone: 602-723-1494