Healthcare Provider Details

I. General information

NPI: 1295445005
Provider Name (Legal Business Name): JOSHUA DOMINIC MONGILLO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11873 SPRINGS RD UNIT 125
CONIFER CO
80433-7263
US

IV. Provider business mailing address

11873 SPRINGS RD STE 120
CONIFER CO
80433-7264
US

V. Phone/Fax

Practice location:
  • Phone: 720-773-2500
  • Fax:
Mailing address:
  • Phone: 720-773-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHR0008473
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberEL2787320
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: