Healthcare Provider Details

I. General information

NPI: 1396255568
Provider Name (Legal Business Name): COLORADO SPORTS CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 28TH ST STE 2
BOULDER CO
80303
US

IV. Provider business mailing address

1440 28TH ST STE 2
BOULDER CO
80303-1030
US

V. Phone/Fax

Practice location:
  • Phone: 303-736-9343
  • Fax: 844-872-5595
Mailing address:
  • Phone: 303-736-9343
  • Fax: 844-872-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHR.0007584
License Number StateCO

VIII. Authorized Official

Name: DR. JOHN MICHAEL MINEN
Title or Position: OWNER
Credential: DC
Phone: 303-736-9343