Provider Demographics
NPI:1932404316
Name:MANCUSO CHIRO CENTER LLC
Entity type:Organization
Organization Name:MANCUSO CHIRO CENTER LLC
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:480-510-3566
Mailing Address - Street 1:18205 N 51ST AVE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1490
Mailing Address - Country:US
Mailing Address - Phone:602-354-4370
Mailing Address - Fax:602-354-4695
Practice Address - Street 1:18205 N 51ST AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1490
Practice Address - Country:US
Practice Address - Phone:602-354-4370
Practice Address - Fax:602-354-4695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-17
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ143840Medicare PIN