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General NPI Number Information
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NPI Number | 1548569155
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Entity Type | Organization
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Legal Business Name | CANYON CHIROPRACTIC WELLNESS CENTER LLC
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Dates
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Enumeration Date | 03/22/2011
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Last Update Date | 03/22/2011
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Provider Practice Location Address
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Address Line | 1425 HAWK PKWY SUITE 1
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City | MONTROSE
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State | CO
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Zip | 81401-6453
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Country | US
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Telephone | 970-240-2181
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Fax | 970-240-2188
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Provider Business Mailing Address
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Address Line | 1425 HAWK PKWY SUITE 1
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City | MONTROSE
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State | CO
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Zip | 81401-6453
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Country | US
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Telephone | 970-240-2181
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Fax | 970-240-2188
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. BRETT LAWTON EDEKER
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Credential | D.C.
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Telephone | 970-240-2181
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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 | 4863
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License Number State | CO
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