Provider Demographics
NPI:1760519409
Name:CREEDE CHIROPRACTIC AND KINESIOLOGY CLINIC, INC
Entity Type:Organization
Organization Name:CREEDE CHIROPRACTIC AND KINESIOLOGY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, DC
Authorized Official - Phone:719-658-3079
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:CREEDE
Mailing Address - State:CO
Mailing Address - Zip Code:81130-0123
Mailing Address - Country:US
Mailing Address - Phone:719-658-3079
Mailing Address - Fax:
Practice Address - Street 1:493 SOUTH MAIN ST.
Practice Address - Street 2:
Practice Address - City:CREEDE
Practice Address - State:CO
Practice Address - Zip Code:81130
Practice Address - Country:US
Practice Address - Phone:719-658-0526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5176111NN1001X
CO5177111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO460018Medicare ID - Type Unspecified
CO459828Medicare ID - Type Unspecified