Provider Demographics
NPI:1275662298
Name:CLUB MANOR CLINIC, INC.
Entity Type:Organization
Organization Name:CLUB MANOR CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-544-7744
Mailing Address - Street 1:1805 FORTINO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1851
Mailing Address - Country:US
Mailing Address - Phone:719-544-7744
Mailing Address - Fax:719-584-2853
Practice Address - Street 1:1805 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1851
Practice Address - Country:US
Practice Address - Phone:719-544-7744
Practice Address - Fax:719-584-2853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5101111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO506658Medicare ID - Type UnspecifiedCLUB MANOR CLINIC