Provider Demographics
NPI:1427564814
Name:JVDC LLC
Entity Type:Organization
Organization Name:JVDC LLC
Other - Org Name:DIVINE SPINE BOULDER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:VALADEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-444-7744
Mailing Address - Street 1:2300 CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5619
Mailing Address - Country:US
Mailing Address - Phone:325-374-9027
Mailing Address - Fax:
Practice Address - Street 1:2300 CANYON BLVD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5619
Practice Address - Country:US
Practice Address - Phone:325-374-9027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty