Provider Demographics
NPI:1124026307
Name:PERUCH, TRACY B (DC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:B
Last Name:PERUCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6770 W DEER VALLEY RD
Mailing Address - Street 2:#B102
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-5956
Mailing Address - Country:US
Mailing Address - Phone:623-362-1950
Mailing Address - Fax:623-572-2741
Practice Address - Street 1:6770 W DEER VALLEY RD
Practice Address - Street 2:#B102
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-5956
Practice Address - Country:US
Practice Address - Phone:623-362-1950
Practice Address - Fax:623-572-2741
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5710111N00000X
AZ09-1105175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z5304OtherHEALTH NET
AZAZ0940160OtherBLUE CROSS BLUE SHEILD
AZAZ78489Medicare ID - Type Unspecified
U65714Medicare UPIN