Healthcare Provider Details

I. General information

NPI: 1568058287
Provider Name (Legal Business Name): MAXIM POWIADA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19120 N PIMA RD STE 100
SCOTTSDALE AZ
85255-5391
US

IV. Provider business mailing address

19120 N PIMA RD STE 100
SCOTTSDALE AZ
85255-5391
US

V. Phone/Fax

Practice location:
  • Phone: 503-701-8147
  • Fax:
Mailing address:
  • Phone: 503-701-8147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number8990
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: