Provider Demographics
NPI:1619365806
Name:FORTMEYER FAMILY WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:FORTMEYER FAMILY WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORTMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-346-7052
Mailing Address - Street 1:328 14TH STREET
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80807
Mailing Address - Country:US
Mailing Address - Phone:719-346-7052
Mailing Address - Fax:719-346-7053
Practice Address - Street 1:328 14TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-1608
Practice Address - Country:US
Practice Address - Phone:719-346-7052
Practice Address - Fax:719-346-7053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1730519844305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service