=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174876015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON OF HEALTH FAMILY CHIROPRACTIC AND NATURAL MEDICINE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2012
-----------------------------------------------------
Last Update Date | 10/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1956 MESQUITE AVE #103
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-854-8005
-----------------------------------------------------
Fax | 928-854-8006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1956 MESQUITE AVE #103
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-5888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-854-8005
-----------------------------------------------------
Fax | 928-854-8006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTIC PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. JENNIFER NICOLE RUSCH GARCIA
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 928-854-8005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 8291
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------