=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811205073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESLEY CAVANAUGH DC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2010
-----------------------------------------------------
Last Update Date | 09/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 W SOUTH BOULDER RD SUITE 2
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80027-1289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-604-6040
-----------------------------------------------------
Fax | 303-313-0994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 317 W SOUTH BOULDER RD SUITE 2
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80027-1289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-604-6040
-----------------------------------------------------
Fax | 303-313-0994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | DR. WESLEY MICHAEL CAVANAUGH
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 303-604-6040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 6428
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------