Healthcare Provider Details

I. General information

NPI: 1720272172
Provider Name (Legal Business Name): HEALTHSOURCE CHIROPRACTIC LLC ARROWHEAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 W KELTON LN STE 150
PEORIA AZ
85382-5010
US

IV. Provider business mailing address

8765 W. KELTON LANE SUITE 150
PEORIA AZ
85382-3802
US

V. Phone/Fax

Practice location:
  • Phone: 626-979-7100
  • Fax: 623-979-3577
Mailing address:
  • Phone: 623-979-7100
  • Fax: 623-979-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberDC5254
License Number StateAZ

VIII. Authorized Official

Name: MRS. DIANA LYNN SRDICH
Title or Position: OWNER
Credential:
Phone: 623-979-7100