MEDICARE: 100 A CHIROPRACTIC WELLNESS CENTER NORTH LLC

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	111N00000X	Chiropractor	6324	CO

General Provider Information

NPI Number	:	1134425325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	100 A CHIROPRACTIC WELLNESS CENTER NORTH LLC

Provider Business Mailing Address
First Line	:	1720 JET STREAM DR
Second Line	:	SUITE 115
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3938
Country	:	US
Telephone Number	:	719-867-3007
Fax Number	:	719-867-3000

Provider Business Practice Location Address
First Line	:	1720 JET STREAM DR
Second Line	:	SUITE 115
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3938
Country	:	US
Telephone Number	:	719-867-3007
Fax Number	:	719-867-3000

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRANDON LIVINGOOD
Credential	:	D.C.
Telephone Number	:	718-867-3007

Provider Enumeration Date	:	02/04/2011
Last Update Date	:	06/05/2020

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