Provider Demographics
NPI:1265557011
Name:PROFESSIONAL SPORTS CHIROPRACTIC LLC
Entity type:Organization
Organization Name:PROFESSIONAL SPORTS CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZMAURICE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:520-296-2515
Mailing Address - Street 1:310 N WILMOT RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2618
Mailing Address - Country:US
Mailing Address - Phone:520-296-2515
Mailing Address - Fax:520-731-6597
Practice Address - Street 1:310 N WILMOT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2618
Practice Address - Country:US
Practice Address - Phone:520-296-2515
Practice Address - Fax:520-731-6597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7023111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0934970OtherBLUE CROSS BLUE SHIELD
AZ1093869646OtherNPI INDIVIDUAL
AZAZ0934970OtherBLUE CROSS BLUE SHIELD
AZZ67786Medicare ID - Type Unspecified