Provider Demographics
NPI:1184987984
Name:HEALTHSOURCE ARVADA PC
Entity type:Organization
Organization Name:HEALTHSOURCE ARVADA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:KONIKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-974-9477
Mailing Address - Street 1:5091 KIPLING ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2325
Mailing Address - Country:US
Mailing Address - Phone:720-974-9477
Mailing Address - Fax:920-974-9481
Practice Address - Street 1:5091 KIPLING ST
Practice Address - Street 2:SUITE 210
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2325
Practice Address - Country:US
Practice Address - Phone:720-974-9477
Practice Address - Fax:920-974-9481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty