MEDICARE: LIFE BALANCE HEALTHCARE 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	5110	CO
2	171100000X	Acupuncturist	5110	CO

General Provider Information

NPI Number	:	1851789838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE BALANCE HEALTHCARE LLC

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

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

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHANE RYAN KOKOSZKA
Credential	:	D.C. C.AC. FIAMA
Telephone Number	:	303-635-2273

Provider Enumeration Date	:	12/29/2014
Last Update Date	:	12/29/2014

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