=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184908659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING PURE CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2011
-----------------------------------------------------
Last Update Date | 10/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17235 N 75TH AVE SUITE F-110
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-0831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-572-4476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17235 N 75TH AVE SUITE F-110
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-0831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MELANIE DIAS-ZAIR
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 623-572-4476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 7419
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------