Healthcare Provider Details

I. General information

NPI: 1821488842
Provider Name (Legal Business Name): GENESIS CHIROPRACTIC SPINE CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5950 S WILLOW DR SUITE 200
GREENWOOD VILLAGE CO
80111-5170
US

IV. Provider business mailing address

5950 S WILLOW DR SUITE 200
GREENWOOD VILLAGE CO
80111-5170
US

V. Phone/Fax

Practice location:
  • Phone: 720-515-8002
  • Fax:
Mailing address:
  • Phone: 720-515-8002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberEL.2786103
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberCHR.0006922
License Number StateCO

VIII. Authorized Official

Name: CLYDE JOHNSON
Title or Position: OWNER
Credential: DC- MS REHAB, MS-NUT
Phone: 720-515-8002