Provider Demographics
NPI:1669685095
Name:VISE, DOUGLAS WAYNE (DC)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:VISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 KIPLING ST STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-2848
Mailing Address - Country:US
Mailing Address - Phone:303-238-0545
Mailing Address - Fax:303-238-5553
Practice Address - Street 1:1701 KIPLING ST STE 105
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-2848
Practice Address - Country:US
Practice Address - Phone:303-238-0545
Practice Address - Fax:303-238-5553
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2497OtherLICENSE #
CO26063Medicare ID - Type Unspecified