Provider Demographics
NPI:1063771368
Name:BRONSON CHIROPRACTIC CLINIC P.C.
Entity type:Organization
Organization Name:BRONSON CHIROPRACTIC CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:BRONSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-789-1078
Mailing Address - Street 1:18631 N 19TH AVE
Mailing Address - Street 2:SUITE 152
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5299
Mailing Address - Country:US
Mailing Address - Phone:602-789-1078
Mailing Address - Fax:623-582-0997
Practice Address - Street 1:18631 N 19TH AVE
Practice Address - Street 2:SUITE 152
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5299
Practice Address - Country:US
Practice Address - Phone:602-789-1078
Practice Address - Fax:623-582-0997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3217111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ525834Medicaid
AZU33635Medicare UPIN