Healthcare Provider Details

I. General information

NPI: 1699885558
Provider Name (Legal Business Name): ROY MONTGOMERY WILBURN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MONTY WILBURN D.C.

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 ROBERTSON ST
FORT COLLINS CO
80524-3926
US

IV. Provider business mailing address

1035 ROBERTSON ST
FORT COLLINS CO
80524-3926
US

V. Phone/Fax

Practice location:
  • Phone: 970-224-2282
  • Fax: 970-495-6955
Mailing address:
  • Phone: 970-224-2282
  • Fax: 970-495-6955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3311
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: