Provider Demographics
NPI:1891828364
Name:GOLLY, ALBERT MARTIN (DC)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:MARTIN
Last Name:GOLLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25144
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80936-5144
Mailing Address - Country:US
Mailing Address - Phone:719-596-2455
Mailing Address - Fax:719-596-2421
Practice Address - Street 1:2410 N POWERS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1533
Practice Address - Country:US
Practice Address - Phone:719-596-2455
Practice Address - Fax:719-596-2421
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO996111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO486598Medicare ID - Type UnspecifiedPROVIDER NUMBER