MEDICARE: DR. SHANE RYAN KOKOSZKA DC

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	5110	CO

General Provider Information

NPI Number	:	1396821476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANE RYAN KOKOSZKA DC

Provider Business Mailing Address
First Line	:	3220 W 62ND AVE
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80221-1907
Country	:	US
Telephone Number	:	303-635-2273
Fax Number	:	303-635-1225

Provider Business Practice Location Address
First Line	:	7695 CHURCH RANCH BLVD
Second Line	:	SUITE 200
City	:	WESTMINSTER
State	:	CO
Zip	:	80021-5544
Country	:	US
Telephone Number	:	303-635-2273
Fax Number	:	303-635-1225

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

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/08/2007

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