Healthcare Provider Details

I. General information

NPI: 1932156429
Provider Name (Legal Business Name): PREFERRED CHIROPRACTIC TWELVE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E WACKER DR STE. 1210
CHICAGO IL
60601-3713
US

IV. Provider business mailing address

5024 S ASH AVE STE. 106
TEMPE AZ
85282-6847
US

V. Phone/Fax

Practice location:
  • Phone: 312-819-0374
  • Fax:
Mailing address:
  • Phone: 480-893-8600
  • Fax: 480-756-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS H BLACK
Title or Position: VICE-PRESIDENT
Credential:
Phone: 480-893-8600