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General NPI Number Information
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NPI Number | 1205187689
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Entity Type | Organization
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Legal Business Name | WIDMAIER CHIROPRACTIC
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Dates
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Enumeration Date | 09/26/2012
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Last Update Date | 02/18/2021
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Provider Practice Location Address
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Address Line | 5080 N 40TH ST STE 104
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City | PHOENIX
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State | AZ
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Zip | 85018-2158
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Country | US
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Telephone | 602-954-6200
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Fax | 602-956-1582
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Provider Business Mailing Address
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Address Line | 5080 N 40TH ST STE 104
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City | PHOENIX
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State | AZ
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Zip | 85018-2158
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Country | US
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Telephone | 602-954-6200
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Fax | 602-956-1582
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Authorized Official
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Title or Position | PRESIDENT
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Name | RANDALL S WIDMAIER
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Credential | DC
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Telephone | 602-954-6200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 4220
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License Number State | AZ
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