Provider Demographics
NPI:1851449920
Name:VAIL MED INC
Entity Type:Organization
Organization Name:VAIL MED INC
Other - Org Name:VAIL INTEGRATIVE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEKANICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DACBSP, EMT,CSCS
Authorized Official - Phone:970-926-4600
Mailing Address - Street 1:PO BOX 2637
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2637
Mailing Address - Country:US
Mailing Address - Phone:970-926-4600
Mailing Address - Fax:970-926-4602
Practice Address - Street 1:0105 EDWARDS VILLAGE CENTER
Practice Address - Street 2:A203
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-926-4600
Practice Address - Fax:970-926-4602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4030111N00000X
CO111222251X0800X
261QP2300X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU53509Medicare UPIN
COC800167Medicare UPIN