=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326603358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMBERLINE WELLNESS CENTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2019
-----------------------------------------------------
Last Update Date | 05/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3303 S LINDSAY RD STE 110
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-283-3168
-----------------------------------------------------
Fax | 480-571-3062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4694 S KIRBY ST
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-8275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-283-3168
-----------------------------------------------------
Fax | 480-571-3062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTIC PHYSICIAN
-----------------------------------------------------
Name | DR. COOPER ANDERSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 480-283-3168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------