Provider Demographics
NPI:1174706261
Name:DC FAMILY CHIROPRACTIC INC
Entity type:Organization
Organization Name:DC FAMILY CHIROPRACTIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:BUCKHAULTS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-275-4757
Mailing Address - Street 1:212 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2423
Mailing Address - Country:US
Mailing Address - Phone:719-275-4757
Mailing Address - Fax:
Practice Address - Street 1:212 N 19TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2423
Practice Address - Country:US
Practice Address - Phone:719-275-4757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO 4711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804526Medicare PIN