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General NPI Number Information
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NPI Number | 1811266125
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE HEALTH & WELLNESS LLC
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Dates
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Enumeration Date | 12/16/2011
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Last Update Date | 12/16/2011
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Provider Practice Location Address
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Address Line | 1499 W 120TH AVE SUITE 130
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City | WESTMINSTER
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State | CO
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Zip | 80234-2995
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Country | US
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Telephone | 303-255-6980
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Fax | 303-255-6899
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Provider Business Mailing Address
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Address Line | 1499 W 120TH AVE SUITE 130
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City | WESTMINSTER
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State | CO
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Zip | 80234-2995
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Country | US
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Telephone | 303-255-6980
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Fax | 303-255-6899
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Authorized Official
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Title or Position | OWNER
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Name | DR. SHANE W LEAR
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Credential | DC
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Telephone | 303-255-6980
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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 | 6683
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License Number State | CO
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