Provider Demographics
NPI:1992255798
Name:EAST VALLEY PHYSICIANS GROUP
Entity type:Organization
Organization Name:EAST VALLEY PHYSICIANS GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:KETCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-924-7632
Mailing Address - Street 1:2044 N RECKER RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-2744
Mailing Address - Country:US
Mailing Address - Phone:480-924-7632
Mailing Address - Fax:
Practice Address - Street 1:2044 N RECKER RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2744
Practice Address - Country:US
Practice Address - Phone:480-924-7632
Practice Address - Fax:480-924-7622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8573111N00000X
AZ5173111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ93305Medicare UPIN