Provider Demographics
NPI:1689801276
Name:VITAL ENERGY CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:VITAL ENERGY CHIROPRACTIC, PC
Other - Org Name:VITAL ENERGY WELLNESS & CHIROPRACTIC CENTER, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOMER
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:D,C,
Authorized Official - Phone:303-463-9395
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80402-0686
Mailing Address - Country:US
Mailing Address - Phone:303-463-9395
Mailing Address - Fax:303-403-4219
Practice Address - Street 1:6355 WARD RD
Practice Address - Street 2:SUITE 420
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-3819
Practice Address - Country:US
Practice Address - Phone:303-463-9395
Practice Address - Fax:303-403-4219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2073111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1518140029OtherINDIVIDUAL NPI