Provider Demographics
NPI:1811205073
Name:WESLEY CAVANAUGH DC, LLC
Entity Type:Organization
Organization Name:WESLEY CAVANAUGH DC, LLC
Other - Org Name:FOUNDATION WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-604-6040
Mailing Address - Street 1:317 W SOUTH BOULDER RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-1289
Mailing Address - Country:US
Mailing Address - Phone:303-604-6040
Mailing Address - Fax:303-313-0994
Practice Address - Street 1:317 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1289
Practice Address - Country:US
Practice Address - Phone:303-604-6040
Practice Address - Fax:303-313-0994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6428261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center