Healthcare Provider Details

I. General information

NPI: 1295937589
Provider Name (Legal Business Name): GEORGE LYNN BARDWELL D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 N GRAND CANYON BLVD.
WILLIAMS AZ
86046-2200
US

IV. Provider business mailing address

706 N GRAND CANYON BLVD
WILLIAMS AZ
86046-2016
US

V. Phone/Fax

Practice location:
  • Phone: 928-635-9115
  • Fax: 928-635-9115
Mailing address:
  • Phone: 928-635-9115
  • Fax: 928-635-9115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number898
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: