MEDICARE: HEALTHSOURCE OF HIGHLANDS RANCH WEST LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NR0400X	Rehabilitation Chiropractor	20161654184	CO

General Provider Information

NPI Number	:	1588114987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSOURCE OF HIGHLANDS RANCH WEST LLC.

Provider Business Mailing Address
First Line	:	9249 S BROADWAY
Second Line	:	UNIT 100
City	:	HIGHLANDS RANCH
State	:	CO
Zip	:	80129-5690
Country	:	US
Telephone Number	:	303-470-1020
Fax Number	:	303-470-1702

Provider Business Practice Location Address
First Line	:	9249 S BROADWAY
Second Line	:	UNIT 100
City	:	HIGHLANDS RANCH
State	:	CO
Zip	:	80129-5690
Country	:	US
Telephone Number	:	303-470-1020
Fax Number	:	303-470-1702

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. SHANNON HURLEY
Credential	:	D.C.
Telephone Number	:	303-470-1020

Provider Enumeration Date	:	10/10/2016
Last Update Date	:	10/10/2016

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