=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295870988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUCKEYE HEALING ARTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 N 4TH ST
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85326-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-393-8767
-----------------------------------------------------
Fax | 623-393-9115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 126
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85326-0011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-393-8767
-----------------------------------------------------
Fax | 623-393-9115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRIAN EDWARD WURST
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 623-393-8767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 4943
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------