=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447638242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MVMT SPORT & WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2015
-----------------------------------------------------
Last Update Date | 05/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18777 N 32ND ST STE 80
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85050-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-788-3365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18777 N 32ND ST STE 80
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85050-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-788-3365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. JUSTINE N LOMBOY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 480-788-3365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8453
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------