Provider Demographics
NPI:1396888905
Name:CEDAREDGE CHIROPRACTIC INC.
Entity type:Organization
Organization Name:CEDAREDGE CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-856-7700
Mailing Address - Street 1:105 SE FRONTIER AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CEDAREDGE
Mailing Address - State:CO
Mailing Address - Zip Code:81413-4020
Mailing Address - Country:US
Mailing Address - Phone:970-856-7700
Mailing Address - Fax:970-856-7927
Practice Address - Street 1:105 SE FRONTIER AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CEDAREDGE
Practice Address - State:CO
Practice Address - Zip Code:81413-4020
Practice Address - Country:US
Practice Address - Phone:970-856-7700
Practice Address - Fax:970-856-7927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4935111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO467428Medicare ID - Type UnspecifiedMEDICARE GROUP#
CO467438Medicare PIN