Healthcare Provider Details

I. General information

NPI: 1588114987
Provider Name (Legal Business Name): HEALTHSOURCE OF HIGHLANDS RANCH WEST LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9249 S BROADWAY UNIT 100
HIGHLANDS RANCH CO
80129-5690
US

IV. Provider business mailing address

9249 S BROADWAY UNIT 100
HIGHLANDS RANCH CO
80129-5690
US

V. Phone/Fax

Practice location:
  • Phone: 303-470-1020
  • Fax: 303-470-1702
Mailing address:
  • Phone: 303-470-1020
  • Fax: 303-470-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number20161654184
License Number StateCO

VIII. Authorized Official

Name: DR. SHANNON HURLEY
Title or Position: PARTNER
Credential: D.C.
Phone: 303-470-1020