=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477805802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS POFF D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2012
-----------------------------------------------------
Last Update Date | 10/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4350 E RAY RD STE 101B
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85044-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-440-8116
-----------------------------------------------------
Fax | 480-759-0024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4350 E RAY RD STE 101B
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85044-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-440-8116
-----------------------------------------------------
Fax | 480-759-0024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8240
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------