=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124093422
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK JOSEPH KLINGERT DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2006
-----------------------------------------------------
Last Update Date | 07/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16816 N 35 AVE STE 8
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85053-2801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-843-3788
-----------------------------------------------------
Fax | 602-843-6485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16319 N 36 AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-978-0506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3372
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------