MEDICARE: AVONDALE CHIROPRACTIC CLINIC

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

General Provider Information

NPI Number	:	1699937037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVONDALE CHIROPRACTIC CLINIC

Provider Business Mailing Address
First Line	:	13050 W RANCHO SANTA FE BLVD
Second Line	:	STE B-5
City	:	AVONDALE
State	:	AZ
Zip	:	85392-1756
Country	:	US
Telephone Number	:	623-535-8984
Fax Number	:

Provider Business Practice Location Address
First Line	:	13050 W RANCHO SANTA FE BLVD
Second Line	:	STE B-5
City	:	AVONDALE
State	:	AZ
Zip	:	85392-1756
Country	:	US
Telephone Number	:	623-535-8984
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SKY MOORE
Credential	:
Telephone Number	:	623-535-8984

Provider Enumeration Date	:	06/26/2008
Last Update Date	:	06/26/2008

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