=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992119820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTGOMERY FAMILY CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2014
-----------------------------------------------------
Last Update Date | 08/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5690 W 88TH AVE
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80031-3005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-210-6073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5690 W 88TH AVE
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80031-3005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-210-6073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRADLEY JOHN MONTGOMERY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 303-210-6073
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHR0007047
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------