Healthcare Provider Details

I. General information

NPI: 1477898104
Provider Name (Legal Business Name): EDWARD A. MADRID, DC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18631 N 19TH AVE STE 152
PHOENIX AZ
85027-5800
US

IV. Provider business mailing address

18631 N 19TH AVE STE 152
PHOENIX AZ
85027-5800
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: EDWARD MADRID
Title or Position: PRESIDENT
Credential: DC
Phone: 602-789-1078