MEDICARE: BOVADILLA CHIROPRACTIC CLINIC INC

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	171100000X	Acupuncturist
2	111N00000X	Chiropractor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1417975897	OTHER	OK	NPI OF DOCTOR

General Provider Information

NPI Number	:	1366505836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOVADILLA CHIROPRACTIC CLINIC INC

Provider Business Mailing Address
First Line	:	4045 WADSWORTH BLVD STE 307
Second Line	:
City	:	WHEAT RIDGE
State	:	CO
Zip	:	80033-4626
Country	:	US
Telephone Number	:	303-647-8131
Fax Number	:	918-493-1773

Provider Business Practice Location Address
First Line	:	4045 WADSWORTH BLVD STE 307
Second Line	:
City	:	WHEAT RIDGE
State	:	CO
Zip	:	80033-4626
Country	:	US
Telephone Number	:	303-647-8131
Fax Number	:	918-770-8208

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	GEORGE BOVADILLA
Credential	:	D.C.
Telephone Number	:	918-850-6000

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	10/05/2022

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