Provider Demographics
NPI:1134425325
Name:100 A CHIROPRACTIC WELLNESS CENTER NORTH LLC
Entity type:Organization
Organization Name:100 A CHIROPRACTIC WELLNESS CENTER NORTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVINGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-867-3007
Mailing Address - Street 1:1720 JET STREAM DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3938
Mailing Address - Country:US
Mailing Address - Phone:719-867-3007
Mailing Address - Fax:719-867-3000
Practice Address - Street 1:1720 JET STREAM DR
Practice Address - Street 2:SUITE 115
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3938
Practice Address - Country:US
Practice Address - Phone:719-867-3007
Practice Address - Fax:719-867-3000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6324111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA103951Medicare PIN