Provider Demographics
NPI:1184838757
Name:ASRC FORT COLLINS P.C. LLC
Entity Type:Organization
Organization Name:ASRC FORT COLLINS P.C. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:307-637-7055
Mailing Address - Street 1:1330 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5917
Mailing Address - Country:US
Mailing Address - Phone:307-637-7055
Mailing Address - Fax:307-637-7055
Practice Address - Street 1:4103 BOARDWALK DRIVE STE 202
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5930
Practice Address - Country:US
Practice Address - Phone:970-377-2922
Practice Address - Fax:970-377-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5545111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC801327Medicare PIN
COU95067Medicare UPIN