Provider Demographics
NPI:1902370810
Name:ASPEN INJURY CENTER LLC
Entity Type:Organization
Organization Name:ASPEN INJURY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:RENEUA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-767-3788
Mailing Address - Street 1:1260 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-2217
Mailing Address - Country:US
Mailing Address - Phone:541-767-3788
Mailing Address - Fax:541-946-1057
Practice Address - Street 1:1260 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2217
Practice Address - Country:US
Practice Address - Phone:541-767-3788
Practice Address - Fax:541-946-1057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5112OtherCHIROPRACTIC