Provider Demographics
NPI:1518051507
Name:SUMMIT CHIROPRACTIC CLINIC OF SOUTH DENVER, INC
Entity Type:Organization
Organization Name:SUMMIT CHIROPRACTIC CLINIC OF SOUTH DENVER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FULLINWIDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-795-2300
Mailing Address - Street 1:9898 S. ROSEMONT AVE.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-4107
Mailing Address - Country:US
Mailing Address - Phone:303-795-2300
Mailing Address - Fax:
Practice Address - Street 1:9898 S. ROSEMONT AVE.
Practice Address - Street 2:SUITE 204
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-4107
Practice Address - Country:US
Practice Address - Phone:303-795-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3647111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4338Medicare PIN