=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518364975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 5280 BALANCED HEALTH CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2014
-----------------------------------------------------
Last Update Date | 02/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5690 DTC BLVD SUITE 140E
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-3232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-915-7997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5690 DTC BLVD SUITE 140E
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-3232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-915-7997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KATHRYN MAE DECKER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 303-915-7997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHR.0006640
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------