Provider Demographics
NPI:1538223508
Name:LEISURE WORLD PLAZA CHIROPRACTIC
Entity type:Organization
Organization Name:LEISURE WORLD PLAZA CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-396-2484
Mailing Address - Street 1:6750 E BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1700
Mailing Address - Country:US
Mailing Address - Phone:480-396-2484
Mailing Address - Fax:480-830-2790
Practice Address - Street 1:6750 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1700
Practice Address - Country:US
Practice Address - Phone:480-396-2484
Practice Address - Fax:480-830-2790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCHQAMedicare PIN
AZU06111Medicare UPIN