Provider Demographics
NPI:1548569155
Name:CANYON CHIROPRACTIC WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CANYON CHIROPRACTIC WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:LAWTON
Authorized Official - Last Name:EDEKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-240-2181
Mailing Address - Street 1:1425 HAWK PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-6453
Mailing Address - Country:US
Mailing Address - Phone:970-240-2181
Mailing Address - Fax:970-240-2188
Practice Address - Street 1:1425 HAWK PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-6453
Practice Address - Country:US
Practice Address - Phone:970-240-2181
Practice Address - Fax:970-240-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU78082Medicare UPIN