MEDICARE: JOHN Q QUACKENBUSH D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3034	CO
2	111N00000X	Chiropractor	7143	AZ

General Provider Information

NPI Number	:	1669427233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN Q QUACKENBUSH D.C.

Provider Business Mailing Address
First Line	:	42104 N VENTURE DRIVE
Second Line	:	SUITE 101
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3823
Country	:	US
Telephone Number	:	623-551-9100
Fax Number	:	623-551-9103

Provider Business Practice Location Address
First Line	:	42104 N VENTURE DRIVE
Second Line	:	SUITE 101
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3823
Country	:	US
Telephone Number	:	623-551-9100
Fax Number	:	623-551-9103

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/23/2009

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