Provider Demographics
NPI:1942340732
Name:CONNELLY, CHE C (DC)
Entity Type:Individual
Prefix:
First Name:CHE
Middle Name:C
Last Name:CONNELLY
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 1:700 KEN PRATT BLVD
Mailing Address - Street 2:#122
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6452
Mailing Address - Country:US
Mailing Address - Phone:303-776-5535
Mailing Address - Fax:303-776-3244
Practice Address - Street 1:700 KEN PRATT BLVD
Practice Address - Street 2:#122
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6452
Practice Address - Country:US
Practice Address - Phone:303-776-5535
Practice Address - Fax:303-776-3244
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4405111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU65471Medicare UPIN
COC46513Medicare PIN