Healthcare Provider Details

I. General information

NPI: 1841275385
Provider Name (Legal Business Name): KSE CHIROPRACTIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8251 W THUNDERBIRD RD SUITE 120
PEORIA AZ
85381-4602
US

IV. Provider business mailing address

8251 W THUNDERBIRD RD SUITE 120
PEORIA AZ
85381-4602
US

V. Phone/Fax

Practice location:
  • Phone: 623-773-0505
  • Fax: 623-773-0405
Mailing address:
  • Phone: 623-773-0505
  • Fax: 623-773-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License NumberAZ4824
License Number StateAZ

VIII. Authorized Official

Name: DR. KENDALL S. ERETH
Title or Position: PRESIDENT
Credential: D.C.
Phone: 623-773-0505