Healthcare Provider Details

I. General information

NPI: 1447495932
Provider Name (Legal Business Name): LIFESPORT CHIROPRACTIC CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 VALMONT RD STE. 100
BOULDER CO
80301-1396
US

IV. Provider business mailing address

2955 VALMONT RD STE. 100
BOULDER CO
80301-1396
US

V. Phone/Fax

Practice location:
  • Phone: 303-877-1458
  • Fax:
Mailing address:
  • Phone: 303-877-1458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number6225
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number6225
License Number StateCO

VIII. Authorized Official

Name: DR. LISA M ERIKSON
Title or Position: SOLE PROPRIETOR
Credential: DC
Phone: 303-877-1458