Provider Demographics
NPI:1750619771
Name:BREITLOW, JAY DALE (DC)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:DALE
Last Name:BREITLOW
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 1:600 S AIRPORT RD
Mailing Address - Street 2:BUILDING C, SUITE C
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-6424
Mailing Address - Country:US
Mailing Address - Phone:804-366-5461
Mailing Address - Fax:
Practice Address - Street 1:600 S AIRPORT RD
Practice Address - Street 2:BUILDING C, SUITE C
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6424
Practice Address - Country:US
Practice Address - Phone:804-366-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011566111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor