Healthcare Provider Details

I. General information

NPI: 1558539858
Provider Name (Legal Business Name): 27TH AVE MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4527 N 27TH AVE
PHOENIX AZ
85017-3702
US

IV. Provider business mailing address

4527 N 27TH AVE
PHOENIX AZ
85017-3702
US

V. Phone/Fax

Practice location:
  • Phone: 602-249-4508
  • Fax: 602-249-1614
Mailing address:
  • Phone: 602-249-4508
  • Fax: 602-249-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1026
License Number StateAZ

VIII. Authorized Official

Name: DR. ROGER H BAKER
Title or Position: OWNER
Credential: D.C.
Phone: 602-249-4508