Healthcare Provider Details

I. General information

NPI: 1659694156
Provider Name (Legal Business Name): ASPEN RAE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21681 N 77TH AVE SUITE 1415
PEORIA AZ
85382-2132
US

IV. Provider business mailing address

21681 N 77TH AVE SUITE 1415
PEORIA AZ
85382-2132
US

V. Phone/Fax

Practice location:
  • Phone: 623-572-9200
  • Fax: 623-572-9204
Mailing address:
  • Phone: 623-572-9200
  • Fax: 623-572-9204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number7250
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number2747
License Number StateAZ

VIII. Authorized Official

Name: DR. SHANE ASPEN MCCALL
Title or Position: OWNER/ DOCTOR
Credential: D.C.
Phone: 623-572-9200