Healthcare Provider Details

I. General information

NPI: 1033526389
Provider Name (Legal Business Name): DENVER SPORT & SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 S WADSWORTH BLVD SUITE 325
LAKEWOOD CO
80235-2203
US

IV. Provider business mailing address

3900 S WADSWORTH BLVD SUITE 325
LAKEWOOD CO
80235-2203
US

V. Phone/Fax

Practice location:
  • Phone: 303-634-2975
  • Fax: 303-634-2976
Mailing address:
  • Phone: 303-634-2975
  • Fax: 303-634-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License NumberCHR.0005662
License Number StateCO

VIII. Authorized Official

Name: DR. JASON ANDREW GRIDLEY
Title or Position: OWNER
Credential: D.C.
Phone: 303-634-2975