Healthcare Provider Details

I. General information

NPI: 1245423268
Provider Name (Legal Business Name): FOUNTAIN CREEK CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18401 HIGHWAY 24 STE 120
WOODLAND PARK CO
80863-9036
US

IV. Provider business mailing address

18401 HIGHWAY 24 STE 120
WOODLAND PARK CO
80863-9036
US

V. Phone/Fax

Practice location:
  • Phone: 719-687-6683
  • Fax: 888-972-5776
Mailing address:
  • Phone: 719-687-6683
  • Fax: 888-972-5776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5709
License Number StateCO

VIII. Authorized Official

Name: DR. JAMES RUSSELL WILEY
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 719-687-6683