=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144226747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVONDALE ACCIDENT & PAIN CHIROPRACTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11335 W BUCKEYE RD STE C104
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-6814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-936-6111
-----------------------------------------------------
Fax | 623-936-1629
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11335 W BUCKEYE RD STE C104
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-6814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-936-6111
-----------------------------------------------------
Fax | 623-936-1629
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DR. ROBERTO FERNANDEZ CUNANAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 622-936-6111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | AZ7287
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------