Provider Demographics
NPI:1477887354
Name:COUNTRY CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:COUNTRY CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BART
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-468-2717
Mailing Address - Street 1:1120 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-1906
Mailing Address - Country:US
Mailing Address - Phone:719-468-2717
Mailing Address - Fax:719-468-2427
Practice Address - Street 1:1120 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1906
Practice Address - Country:US
Practice Address - Phone:719-468-2717
Practice Address - Fax:719-468-2427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty