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General NPI Number Information
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NPI Number | 1003096363
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Entity Type | Organization
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Legal Business Name | RENAISSANCE CHIROPRACTIC P C
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Dates
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Enumeration Date | 11/05/2007
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Last Update Date | 11/05/2007
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Provider Practice Location Address
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Address Line | 112 N CENTRAL AVE A2
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City | PHOENIX
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State | AZ
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Zip | 85004-2309
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Country | US
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Telephone | 602-712-9444
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Fax | 602-258-7844
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Provider Business Mailing Address
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Address Line | 112 N CENTRAL AVE A2
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City | PHOENIX
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State | AZ
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Zip | 85004-2309
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Country | US
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Telephone | 602-712-9444
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Fax | 602-258-7844
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | DR. REBECCA DAWN CARLSON
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Credential | D.C.
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Telephone | 602-712-9444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5145
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License Number State | AZ
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