1023279106 NPI number — MRS. DESIREE BLAIRE BUKOVSKY P.T., DPT

Table of content: MRS. DESIREE BLAIRE BUKOVSKY P.T., DPT (NPI 1023279106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023279106 NPI number — MRS. DESIREE BLAIRE BUKOVSKY P.T., DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUKOVSKY
Provider First Name:
DESIREE
Provider Middle Name:
BLAIRE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T., DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WRIGHT
Provider Other First Name:
DESIREE
Provider Other Middle Name:
BLAIRE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T., DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023279106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2312 LIMOUSIN COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-589-4709
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4674 SNOW MESA DR
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80528-8615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-266-3850
Provider Business Practice Location Address Fax Number:
970-266-3855
Provider Enumeration Date:
06/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  22569 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 9650 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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