Provider Demographics
NPI:1689297400
Name:NEW WAVE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:NEW WAVE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DC AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-772-7337
Mailing Address - Street 1:829 MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-4954
Mailing Address - Country:US
Mailing Address - Phone:303-772-7337
Mailing Address - Fax:
Practice Address - Street 1:829 MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-4954
Practice Address - Country:US
Practice Address - Phone:303-772-7337
Practice Address - Fax:720-378-6541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty