(702) 873-8003 Phone
Home
About Comp/Med
Contact Us
Client Services
Provider Services
Group Information Update
*
Indicates required field
Business Name (DBA)
*
Tax ID Number
*
Billing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Primary Address same as Billing Address
*
[Select]
Yes
No
Primary Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Billing Contact
*
First
Last
Billing Contact Email
*
Credentialing Contact
*
First
Last
Credentialing Contact Email
*
Physician/Chiropractor Information
Provider Name
*
First
Last
Degree
*
Areas of Expertise
*
Neck
Back
Spine
Shoulders
Elbows
Wrists
Hands
Hips
Knees
Ankles
Feet
I agree to receiving marketing and promotional materials
Submit