Provider Demographics
NPI:1417138694
Name:BACK COUNTRY CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:BACK COUNTRY CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC FIAMA
Authorized Official - Phone:303-980-1378
Mailing Address - Street 1:10815 W JEWELL AVE STE P
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-6268
Mailing Address - Country:US
Mailing Address - Phone:303-980-1378
Mailing Address - Fax:303-980-1379
Practice Address - Street 1:10815 W JEWELL AVE STE P
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-6268
Practice Address - Country:US
Practice Address - Phone:303-980-1378
Practice Address - Fax:303-980-1379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4074OtherPTAN