1063732287 NPI number — LAURA NYQUIST, RD, LLC

Table of content: (NPI 1063732287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063732287 NPI number — LAURA NYQUIST, RD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAURA NYQUIST, RD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063732287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20671 WILLOWBEND LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARKER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80138-7122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-805-7801
Provider Business Mailing Address Fax Number:
877-573-6695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11479 S PINE DR STE 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARKER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80134-7308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-473-6694
Provider Business Practice Location Address Fax Number:
877-573-6695
Provider Enumeration Date:
06/10/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NYQUIST
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
REGISTERED DIETITIAN
Authorized Official Telephone Number:
740-473-6694

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  14277 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 133V00000X , with the licence number: 14277 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: COA101925 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: COA100471 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 1174847552 . This is a "INDIVIDUAL NPI NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1063732287 . This is a "GROUP NPI" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".