Provider Demographics
NPI:1588009880
Name:GENESIS CHIROPRACTIC SPINE AND SPORTS CENTER
Entity Type:Organization
Organization Name:GENESIS CHIROPRACTIC SPINE AND SPORTS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-449-7641
Mailing Address - Street 1:7940 S UNIVERSITY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122-5104
Mailing Address - Country:US
Mailing Address - Phone:760-449-7641
Mailing Address - Fax:
Practice Address - Street 1:7940 S UNIVERSITY BLVD, SUITE 100
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122
Practice Address - Country:US
Practice Address - Phone:760-449-7641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR.0006922111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty