Provider Demographics
NPI:1194843573
Name:PENCECHIROPRACTIC
Entity Type:Organization
Organization Name:PENCECHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TI
Authorized Official - Middle Name:ROBERT-VERNON
Authorized Official - Last Name:PENCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-259-1450
Mailing Address - Street 1:523 S CAMINO DEL RIO STE A
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6853
Mailing Address - Country:US
Mailing Address - Phone:970-259-1450
Mailing Address - Fax:970-259-1471
Practice Address - Street 1:523 S CAMINO DEL RIO STE A
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-6853
Practice Address - Country:US
Practice Address - Phone:970-259-1450
Practice Address - Fax:970-259-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5905111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty