=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730433657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EV CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2012
-----------------------------------------------------
Last Update Date | 10/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W GUADALUPE RD SUITE#301
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85233-3332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-892-7500
-----------------------------------------------------
Fax | 480-892-7501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 W GUADALUPE RD SUITE#301
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85233-3332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-892-7500
-----------------------------------------------------
Fax | 480-892-7501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. ANGELA KOWALCZYK
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 480-892-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 7489
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------