Provider Demographics
NPI:1891827648
Name:DE LA VARA CHIROPRACTIC & SPORTS MEDICINE CLINIC, INC.
Entity type:Organization
Organization Name:DE LA VARA CHIROPRACTIC & SPORTS MEDICINE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC AND CERTIFIE
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DE LA VARA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-763-8433
Mailing Address - Street 1:1880 S PIERCE ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-7191
Mailing Address - Country:US
Mailing Address - Phone:303-763-8433
Mailing Address - Fax:303-936-0705
Practice Address - Street 1:1880 S PIERCE ST
Practice Address - Street 2:SUITE 14
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-7191
Practice Address - Country:US
Practice Address - Phone:303-763-8433
Practice Address - Fax:303-936-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36136111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty