Provider Demographics
NPI:1790018018
Name:COLORADO SPRINGS SPORTS CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:COLORADO SPRINGS SPORTS CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:CRYSTAL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-358-9837
Mailing Address - Street 1:611 N NEVADA AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1099
Mailing Address - Country:US
Mailing Address - Phone:719-358-9837
Mailing Address - Fax:719-358-9838
Practice Address - Street 1:611 N NEVADA AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1099
Practice Address - Country:US
Practice Address - Phone:719-358-9837
Practice Address - Fax:719-358-9838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6270111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty