Provider Demographics
NPI:1912002130
Name:CRISOFULLI, THOMAS (CHHIROPRACTOR)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:CRISOFULLI
Suffix:
Gender:M
Credentials:CHHIROPRACTOR
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 109
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-0109
Mailing Address - Country:US
Mailing Address - Phone:970-949-0444
Mailing Address - Fax:970-949-0883
Practice Address - Street 1:150 E BEAVER CREEK BLVD.
Practice Address - Street 2:106B
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620
Practice Address - Country:US
Practice Address - Phone:970-949-0444
Practice Address - Fax:970-949-0883
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3921111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC454938Medicare ID - Type UnspecifiedMEDICARE