Provider Demographics
NPI:1740402437
Name:ADVANCED CHIROPRACTIC, P.C.
Entity type:Organization
Organization Name:ADVANCED CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PROVICK
Authorized Official - Suffix:
Authorized Official - Credentials:BSC, DC
Authorized Official - Phone:719-539-0528
Mailing Address - Street 1:507 E RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2901
Mailing Address - Country:US
Mailing Address - Phone:719-539-0528
Mailing Address - Fax:719-539-9266
Practice Address - Street 1:507 E RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2901
Practice Address - Country:US
Practice Address - Phone:719-539-0528
Practice Address - Fax:719-539-9266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty