Provider Demographics
NPI:1427112002
Name:LUNDBERG, KEITH (DC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:LUNDBERG
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 1:140 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3663
Mailing Address - Country:US
Mailing Address - Phone:970-249-9626
Mailing Address - Fax:970-249-0964
Practice Address - Street 1:140 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3663
Practice Address - Country:US
Practice Address - Phone:970-249-9626
Practice Address - Fax:970-249-0964
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1960111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17423Medicare ID - Type Unspecified