MEDICARE: DR. MATHEW DAVID ULLOM D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NR0400X	Rehabilitation Chiropractor	6192	CO

General Provider Information

NPI Number	:	1093975203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATHEW DAVID ULLOM D.C.

Provider Business Mailing Address
First Line	:	2550 STOVER ST
Second Line	:	BLDG. F
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4641
Country	:	US
Telephone Number	:	970-491-9191
Fax Number	:	970-223-2293

Provider Business Practice Location Address
First Line	:	2550 STOVER ST
Second Line	:	BLDG. F
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4641
Country	:	US
Telephone Number	:	970-491-9191
Fax Number	:	970-223-2293

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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