MEDICARE: GEORGE BOVADILLA 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	171100000X	Acupuncturist	AC.2786112	CO
2	111N00000X	Chiropractor	CHR.0007121	CO

General Provider Information

NPI Number	:	1417975897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE BOVADILLA D.C.

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	:	303-647-8136
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	:	303-647-8136
Fax Number	:	918-770-8208

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	10/05/2022

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