Healthcare Provider Details

I. General information

NPI: 1578831327
Provider Name (Legal Business Name): VICENTE CHAVIRA D.C, A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 E. RUTH AVE.
PHOENIX AZ
85020-3032
US

IV. Provider business mailing address

1410 E. CHOLLA ST.
PHOENIX AZ
85020-1413
US

V. Phone/Fax

Practice location:
  • Phone: 480-888-5555
  • Fax:
Mailing address:
  • Phone: 480-888-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8328
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR-001261
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: