Healthcare Provider Details

I. General information

NPI: 1003140997
Provider Name (Legal Business Name): FOUNTAIN CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 N SANTA FE AVE
FOUNTAIN CO
80817-1742
US

IV. Provider business mailing address

470 N SANTA FE AVE
FOUNTAIN CO
80817-1742
US

V. Phone/Fax

Practice location:
  • Phone: 719-799-6555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6421
License Number StateCO

VIII. Authorized Official

Name: DR. ARNOLDO A MORAN
Title or Position: CEO & CO-OWNER
Credential: DC
Phone: 719-799-6555