Healthcare Provider Details

I. General information

NPI: 1770888232
Provider Name (Legal Business Name): JASON R GILLIES D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 E FILLMORE ST
COLORADO SPRINGS CO
80907-6375
US

IV. Provider business mailing address

824 E FILLMORE ST
COLORADO SPRINGS CO
80907-6375
US

V. Phone/Fax

Practice location:
  • Phone: 719-634-2579
  • Fax: 719-634-2371
Mailing address:
  • Phone: 719-634-2579
  • Fax: 719-634-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6562
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.0013124
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: