Provider Demographics
NPI:1154572006
Name:MANCUSO CHIROPRACTIC LIFE CENTER
Entity type:Organization
Organization Name:MANCUSO CHIROPRACTIC LIFE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-767-1200
Mailing Address - Street 1:14700 N FRANK LLOYD WRIGHT BLVD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2046
Mailing Address - Country:US
Mailing Address - Phone:480-767-1200
Mailing Address - Fax:480-767-7587
Practice Address - Street 1:14700 N FRANK LLOYD WRIGHT BLVD
Practice Address - Street 2:SUITE 155
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2046
Practice Address - Country:US
Practice Address - Phone:480-767-1200
Practice Address - Fax:480-767-7587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDC5012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty