1194891671 NPI number — VIDA CHIROPRACTIC STUDIO, LLC

Table of content: (NPI 1194891671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194891671 NPI number — VIDA CHIROPRACTIC STUDIO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIDA CHIROPRACTIC STUDIO, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194891671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4650 W 38TH AVE
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80212-2161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-433-5433
Provider Business Mailing Address Fax Number:
303-433-8432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4650 W 38TH AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80212-2161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-433-5433
Provider Business Practice Location Address Fax Number:
303-433-8432
Provider Enumeration Date:
11/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
303-433-5433

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  6077 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7232115 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".