MEDICARE: CHIROPRACTIC ASSOC. OF FT COLLINS

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

General Provider Information

NPI Number	:	1346411386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTIC ASSOC. OF FT COLLINS

Provider Business Mailing Address
First Line	:	4745 BOARDWALK DR UNIT C1
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3769
Country	:	US
Telephone Number	:	970-207-4066
Fax Number	:	970-225-1392

Provider Business Practice Location Address
First Line	:	4745 BOARDWALK DR UNIT C1
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3769
Country	:	US
Telephone Number	:	970-207-4066
Fax Number	:	970-225-1392

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL PUSTILNIK
Credential	:	DC
Telephone Number	:	970-207-4066

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	03/18/2008

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