Provider Demographics
NPI:1982908679
Name:MISSION TRACE CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:MISSION TRACE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:JANUSCHKA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:720-470-3805
Mailing Address - Street 1:3953 E 120TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-2090
Mailing Address - Country:US
Mailing Address - Phone:303-452-2960
Mailing Address - Fax:303-452-1344
Practice Address - Street 1:3953 E 120TH AVE STE B
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-2090
Practice Address - Country:US
Practice Address - Phone:303-452-2960
Practice Address - Fax:303-452-1344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2242111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Single Specialty