=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538394200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHYLLIS CAVANAUGH D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2009
-----------------------------------------------------
Last Update Date | 12/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 NACO RD
-----------------------------------------------------
City | BISBEE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85603-9655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-432-4404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 852
-----------------------------------------------------
City | BISBEE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85603-0852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-432-4044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8049
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------