Provider Demographics
NPI:1457748113
Name:DIVISION STREET CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:DIVISION STREET CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:DICKISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-777-9600
Mailing Address - Street 1:999 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1654
Mailing Address - Country:US
Mailing Address - Phone:928-777-9600
Mailing Address - Fax:928-777-9797
Practice Address - Street 1:999 DIVISION ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1654
Practice Address - Country:US
Practice Address - Phone:928-777-9600
Practice Address - Fax:928-777-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDC5343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty