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General NPI Number Information
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NPI Number | 1245423268
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Entity Type | Organization
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Legal Business Name | FOUNTAIN CREEK CHIROPRACTIC
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Dates
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Enumeration Date | 08/22/2007
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Last Update Date | 05/28/2021
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Provider Practice Location Address
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Address Line | 18401 HIGHWAY 24 STE 120
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City | WOODLAND PARK
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State | CO
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Zip | 80863-9036
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Country | US
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Telephone | 719-687-6683
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Fax | 888-972-5776
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Provider Business Mailing Address
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Address Line | 18401 HIGHWAY 24 STE 120
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City | WOODLAND PARK
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State | CO
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Zip | 80863-9036
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Country | US
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Telephone | 719-687-6683
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Fax | 888-972-5776
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. JAMES RUSSELL WILEY
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Credential | D.C.
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Telephone | 719-687-6683
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5709
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License Number State | CO
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