Provider Demographics
NPI:1902075898
Name:PROFESSIONAL CHIROPRACTIC OFFICE LLC
Entity Type:Organization
Organization Name:PROFESSIONAL CHIROPRACTIC OFFICE LLC
Other - Org Name:PROFESSIONAL CHIROPRACTIC OFFICE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:COLBY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-580-1463
Mailing Address - Street 1:1919 65TH AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7965
Mailing Address - Country:US
Mailing Address - Phone:970-353-5300
Mailing Address - Fax:970-353-5332
Practice Address - Street 1:1919 65TH AVE UNIT A
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-7965
Practice Address - Country:US
Practice Address - Phone:970-353-5300
Practice Address - Fax:970-353-5332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1689111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC542818Medicare PIN