=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174841464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENVER SPINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2010
-----------------------------------------------------
Last Update Date | 05/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1699 S COLORADO BLVD UNIT M
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-953-1471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1699 S COLORADO BLVD UNIT M
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-953-1471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. NIELS JONATHAN PEDERSEN
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 303-953-1471
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NP0017X
-----------------------------------------------------
Taxonomy Name | Pediatric Chiropractor
-----------------------------------------------------
License Number | 6451
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6453
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------