Provider Demographics
NPI:1619066321
Name:ELSEA, MARY G (DC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:ELSEA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 DARLEY AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6537
Mailing Address - Country:US
Mailing Address - Phone:303-499-5000
Mailing Address - Fax:303-499-4962
Practice Address - Street 1:4150 DARLEY AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6537
Practice Address - Country:US
Practice Address - Phone:303-499-5000
Practice Address - Fax:303-499-4962
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
C18141Medicare Oscar/Certification
C18141Medicare PIN