Healthcare Provider Details

I. General information

NPI: 1316370463
Provider Name (Legal Business Name): FRUITA CHIROPRACTIC AND MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E ASPEN AVE UNIT A
FRUITA CO
81521-2542
US

IV. Provider business mailing address

122 E ASPEN AVE UNIT A
FRUITA CO
81521-2542
US

V. Phone/Fax

Practice location:
  • Phone: 970-639-9730
  • Fax: 970-639-9730
Mailing address:
  • Phone: 970-639-9730
  • Fax: 970-639-9730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHR.0006988
License Number StateCO

VIII. Authorized Official

Name: DR. JONATHAN EDWARD BLAHA
Title or Position: OWNER
Credential: D.C.
Phone: 970-639-9730