Provider Demographics
NPI:1992274732
Name:BRAVE ROOTS CHIROPRACTIC
Entity type:Organization
Organization Name:BRAVE ROOTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-460-6770
Mailing Address - Street 1:2111 S COLLEGE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5404
Mailing Address - Country:US
Mailing Address - Phone:970-460-6770
Mailing Address - Fax:866-701-7104
Practice Address - Street 1:2111 S COLLEGE AVE STE B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5404
Practice Address - Country:US
Practice Address - Phone:970-460-6770
Practice Address - Fax:866-701-7104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POLARIS HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-22
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty