Healthcare Provider Details

I. General information

NPI: 1184838757
Provider Name (Legal Business Name): ASRC FORT COLLINS P.C. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 BOARDWALK DRIVE STE 202
FORT COLLINS CO
80525-5930
US

IV. Provider business mailing address

1330 RIDGE ROAD
CHEYENNE WY
82001-5917
US

V. Phone/Fax

Practice location:
  • Phone: 970-377-2922
  • Fax: 970-377-3507
Mailing address:
  • Phone: 307-637-7055
  • Fax: 307-637-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number5545
License Number StateCO

VIII. Authorized Official

Name: MICHAEL KEITH THOMPSON
Title or Position: PRESIDENT
Credential: D.C.
Phone: 307-637-7055