Provider Demographics
NPI:1104963727
Name:GRAHAM, JOHN LOREN (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LOREN
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4383
Mailing Address - Street 2:619 MAIN STREET
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-4383
Mailing Address - Country:US
Mailing Address - Phone:970-668-3299
Mailing Address - Fax:970-668-1774
Practice Address - Street 1:619 MAIN STREET
Practice Address - Street 2:SUITE 5B
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-4383
Practice Address - Country:US
Practice Address - Phone:970-668-3299
Practice Address - Fax:970-668-1774
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5771111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC804401Medicare PIN
COV07938Medicare UPIN