Provider Demographics
NPI:1669606380
Name:MOUNTAIN ROSE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:MOUNTAIN ROSE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:AZELTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:971-322-9791
Mailing Address - Street 1:1811 LODESTONE DR
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-3715
Mailing Address - Country:US
Mailing Address - Phone:971-322-9791
Mailing Address - Fax:
Practice Address - Street 1:113 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3505
Practice Address - Country:US
Practice Address - Phone:971-322-9791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty