Provider Demographics
NPI:1720050420
Name:BUCKHAULTS, DALE CHRIS (DC)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:CHRIS
Last Name:BUCKHAULTS
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 1:212 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2423
Mailing Address - Country:US
Mailing Address - Phone:719-275-4757
Mailing Address - Fax:
Practice Address - Street 1:212 N 19TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2423
Practice Address - Country:US
Practice Address - Phone:719-275-4757
Practice Address - Fax:719-275-4757
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU76689Medicare UPIN
CO811366Medicare PIN