Provider Demographics
NPI:1588846240
Name:INDIGO CHIROPRACTIC INC
Entity type:Organization
Organization Name:INDIGO CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-451-3500
Mailing Address - Street 1:9755 N 90TH ST STE A203
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5079
Mailing Address - Country:US
Mailing Address - Phone:480-661-2903
Mailing Address - Fax:480-451-3500
Practice Address - Street 1:9755 N 90TH ST STE A203
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5079
Practice Address - Country:US
Practice Address - Phone:480-661-2903
Practice Address - Fax:480-451-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7173111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU91352Medicare UPIN
AZ71157Medicare PIN