Provider Demographics
NPI:1114358355
Name:FORM AND FUNCTION CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:FORM AND FUNCTION CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:USEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-988-0328
Mailing Address - Street 1:1041 S HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80246-2307
Mailing Address - Country:US
Mailing Address - Phone:970-988-0328
Mailing Address - Fax:
Practice Address - Street 1:13751 E YALE AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-7351
Practice Address - Country:US
Practice Address - Phone:303-597-9595
Practice Address - Fax:303-597-9689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0006782261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center