Provider Demographics
NPI:1699885558
Name:WILBURN, ROY MONTGOMERY (DC)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:MONTGOMERY
Last Name:WILBURN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MONTY
Other - Middle Name:
Other - Last Name:WILBURN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1035 ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3926
Mailing Address - Country:US
Mailing Address - Phone:970-224-2282
Mailing Address - Fax:970-495-6955
Practice Address - Street 1:1035 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3926
Practice Address - Country:US
Practice Address - Phone:970-224-2282
Practice Address - Fax:970-495-6955
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3311111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC27673Medicare ID - Type Unspecified
COU28715Medicare UPIN