Provider Demographics
NPI:1447395785
Name:CENTENNIAL CHIROPRACTIC CLINIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CENTENNIAL CHIROPRACTIC CLINIC PROFESSIONAL CORPORATION
Other - Org Name:CENTENNIAL CHIROPRACTIC CLINIC, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:OGRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-795-3668
Mailing Address - Street 1:5020 S FEDERAL BLVD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80110-6315
Mailing Address - Country:US
Mailing Address - Phone:303-795-3668
Mailing Address - Fax:303-795-3669
Practice Address - Street 1:5020 S FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80110-6315
Practice Address - Country:US
Practice Address - Phone:303-795-3668
Practice Address - Fax:303-795-3669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1555111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14293Medicare UPIN