Provider Demographics
NPI:1093905887
Name:BOULDER CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:BOULDER CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAD
Authorized Official - Middle Name:N
Authorized Official - Last Name:TENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:702-293-0041
Mailing Address - Street 1:806 BUCHANAN BLVD # 109
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-2130
Mailing Address - Country:US
Mailing Address - Phone:702-293-0041
Mailing Address - Fax:702-293-2834
Practice Address - Street 1:806 BUCHANAN BLVD # 109
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-2130
Practice Address - Country:US
Practice Address - Phone:702-293-0041
Practice Address - Fax:702-293-2834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB-780111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV39140Medicare PIN