1184685323 NPI number — MRS. MARGO C BOATNER PAC

Table of content: MRS. MARGO C BOATNER PAC (NPI 1184685323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184685323 NPI number — MRS. MARGO C BOATNER PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOATNER
Provider First Name:
MARGO
Provider Middle Name:
C
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLLETTE
Provider Other First Name:
MARGO
Provider Other Middle Name:
C.
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184685323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
940 CENTRAL PARK DR
Provider Second Line Business Mailing Address:
STE 280
Provider Business Mailing Address City Name:
STEAMBOAT SPGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-879-6663
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
940 CENTRAL PARK DR
Provider Second Line Business Practice Location Address:
STE 280
Provider Business Practice Location Address City Name:
STEAMBOAT SPGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-879-6663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2006

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 72436069 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2180 . This is a "COLORADO STATE LICENSE" identifier . This identifiers is of the category "OTHER".




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