Provider Demographics
NPI:1245423268
Name:FOUNTAIN CREEK CHIROPRACTIC
Entity Type:Organization
Organization Name:FOUNTAIN CREEK CHIROPRACTIC
Other - Org Name:UTE PASS FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-687-6683
Mailing Address - Street 1:18401 HIGHWAY 24 STE 120
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-9036
Mailing Address - Country:US
Mailing Address - Phone:719-687-6683
Mailing Address - Fax:888-972-5776
Practice Address - Street 1:18401 HIGHWAY 24 STE 120
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-9036
Practice Address - Country:US
Practice Address - Phone:719-687-6683
Practice Address - Fax:888-972-5776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5709111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU99425Medicare UPIN
COC804970Medicare PIN