Provider Demographics
NPI:1174793004
Name:1524 CORPORATION INC.
Entity type:Organization
Organization Name:1524 CORPORATION INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANA
Authorized Official - Middle Name:MARLENE
Authorized Official - Last Name:PROBYN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-985-3040
Mailing Address - Street 1:6047 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-7517
Mailing Address - Country:US
Mailing Address - Phone:480-985-3040
Mailing Address - Fax:480-985-3040
Practice Address - Street 1:6047 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-7517
Practice Address - Country:US
Practice Address - Phone:480-985-3040
Practice Address - Fax:480-985-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU77265Medicare UPIN