Provider Demographics
NPI:1457865313
Name:FAHEY, CULLEN
Entity Type:Individual
Prefix:DR
First Name:CULLEN
Middle Name:
Last Name:FAHEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S JACKSON ST
Mailing Address - Street 2:STE 105
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-3131
Mailing Address - Country:US
Mailing Address - Phone:303-474-4811
Mailing Address - Fax:720-750-6604
Practice Address - Street 1:16197 MAIN AVE SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1704
Practice Address - Country:US
Practice Address - Phone:815-245-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR.0007951111N00000X
MN6403111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor