Healthcare Provider Details

I. General information

NPI: 1043385479
Provider Name (Legal Business Name): EDWARD A MADRID DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18631 N 19TH AVE SUITE 152
PHOENIX AZ
85027-5299
US

IV. Provider business mailing address

18631 N 19TH AVE SUITE 152
PHOENIX AZ
85027-5299
US

V. Phone/Fax

Practice location:
  • Phone: 602-789-1078
  • Fax: 623-582-0997
Mailing address:
  • Phone: 602-789-1078
  • Fax: 623-582-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8560
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: