Provider Demographics
NPI:1821488842
Name:GENESIS CHIROPRACTIC SPINE CTR
Entity Type:Organization
Organization Name:GENESIS CHIROPRACTIC SPINE CTR
Other - Org Name:GENESIS WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC- MS REHAB, MS-NUT
Authorized Official - Phone:720-515-8002
Mailing Address - Street 1:5950 S WILLOW DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-5170
Mailing Address - Country:US
Mailing Address - Phone:720-515-8002
Mailing Address - Fax:
Practice Address - Street 1:5950 S WILLOW DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-5170
Practice Address - Country:US
Practice Address - Phone:720-515-8002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COEL.2786103261QP2000X
COCHR.0006922261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy