=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649502105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOB MATHEWS PERFECT BODY SYSTEM 1 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2010
-----------------------------------------------------
Last Update Date | 02/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 W THOMAS RD SUITE 201
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85013-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-279-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 W THOMAS RD SUITE 201
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85013-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-279-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | ROBERT MATHEWS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-279-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------