Provider Demographics
NPI:1679104178
Name:DESERT SUN CHIROPRACTIC EAST LLC
Entity type:Organization
Organization Name:DESERT SUN CHIROPRACTIC EAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:ONTIVEROS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:915-857-6607
Mailing Address - Street 1:3800 N MESA ST STE C1
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1535
Mailing Address - Country:US
Mailing Address - Phone:915-857-6607
Mailing Address - Fax:915-838-1700
Practice Address - Street 1:1387 GEORGE DIETER DR STE A108
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7410
Practice Address - Country:US
Practice Address - Phone:915-857-6607
Practice Address - Fax:915-838-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-03
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F5089Medicaid
TX8V5180OtherBCBS