Provider Demographics
NPI:1477706760
Name:APPLIED KINESIOLOGICAL GROUP PC
Entity Type:Organization
Organization Name:APPLIED KINESIOLOGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:MIKE
Authorized Official - Last Name:VIDMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-651-1400
Mailing Address - Street 1:420 21ST AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1441
Mailing Address - Country:US
Mailing Address - Phone:303-651-1400
Mailing Address - Fax:303-776-9272
Practice Address - Street 1:420 21ST AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1441
Practice Address - Country:US
Practice Address - Phone:303-651-1400
Practice Address - Fax:303-776-9272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO403287Medicare UPIN
CO13313Medicare PIN