MEDICARE: ASPEN INJURY CENTER 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5112	OTHER	OR	CHIROPRACTIC

General Provider Information

NPI Number	:	1902370810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASPEN INJURY CENTER LLC

Provider Business Mailing Address
First Line	:	1260 E MAIN ST
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-2217
Country	:	US
Telephone Number	:	541-767-3788
Fax Number	:	541-946-1057

Provider Business Practice Location Address
First Line	:	1260 E MAIN ST
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-2217
Country	:	US
Telephone Number	:	541-767-3788
Fax Number	:	541-946-1057

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RICHARD RENEUA
Credential	:	DC
Telephone Number	:	541-767-3788

Provider Enumeration Date	:	01/14/2019
Last Update Date	:	01/14/2019

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