=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891827648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DE LA VARA CHIROPRACTIC & SPORTS MEDICINE CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 02/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1880 S PIERCE ST SUITE 14
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80232-7191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-763-8433
-----------------------------------------------------
Fax | 303-936-0705
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1880 S PIERCE ST SUITE 14
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80232-7191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-763-8433
-----------------------------------------------------
Fax | 303-936-0705
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC AND CERTIFIE
-----------------------------------------------------
Name | MRS. GLORIA LYNN DE LA VARA
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 303-763-8433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 36136
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------