Provider Demographics
NPI:1447464698
Name:HUMPHREYS STREET CHIROPRACTIC
Entity type:Organization
Organization Name:HUMPHREYS STREET CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRIMARY HEALTHCARE PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-774-6601
Mailing Address - Street 1:421 N HUMPHREYS ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4531
Mailing Address - Country:US
Mailing Address - Phone:928-774-6601
Mailing Address - Fax:928-774-2193
Practice Address - Street 1:421 N HUMPHREYS ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4531
Practice Address - Country:US
Practice Address - Phone:928-774-6601
Practice Address - Fax:928-774-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0762111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0244550OtherBLUE CROSS BLUE SHIELD
AZ0244550OtherBLUE CROSS BLUE SHIELD
AZZ20505Medicare ID - Type Unspecified