1235458597 NPI number — RESILIA NEUROTHERAPY SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235458597 NPI number — RESILIA NEUROTHERAPY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESILIA NEUROTHERAPY SERVICES, 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:
1235458597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
503 REMINGTON ST STE 104
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:
80524-3089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-530-0135
Provider Business Mailing Address Fax Number:
970-315-0386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 REMINGTON ST STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80524-3089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-530-0135
Provider Business Practice Location Address Fax Number:
970-315-0386
Provider Enumeration Date:
05/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
MICHAELE
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
970-350-0135

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  22494 , 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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