1003209248 NPI number — AZEAL DERMATOLOGY INSTITUTE, LLC

Table of content: (NPI 1003209248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003209248 NPI number — AZEAL DERMATOLOGY INSTITUTE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AZEAL DERMATOLOGY INSTITUTE, 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:
1003209248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7446
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80537-0446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-663-2742
Provider Business Mailing Address Fax Number:
970-667-0847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5365 SPINE RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80301-3324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-530-9325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PILKINGTON
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
303-530-9325

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 77885376 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".