Healthcare Provider Details

I. General information

NPI: 1447577416
Provider Name (Legal Business Name): JUAN RICK ROYBAL III D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11030 N TATUM BLVD STE 102
PHOENIX AZ
85028-6073
US

IV. Provider business mailing address

11030 N TATUM BLVD STE 102
PHOENIX AZ
85028-6073
US

V. Phone/Fax

Practice location:
  • Phone: 602-494-3037
  • Fax:
Mailing address:
  • Phone: 602-494-3037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8138
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: