1396294047 NPI number — MELINDA CICOFF LMT

Table of content: MELINDA CICOFF LMT (NPI 1396294047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396294047 NPI number — MELINDA CICOFF LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CICOFF
Provider First Name:
MELINDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KULICK
Provider Other First Name:
MELINDA
Provider Other Middle Name:
LORELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396294047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 DUESENBERG LN
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:
80524-3236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-388-7293
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 DUESENBERG LN
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:
80524-3236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-388-7293
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2016

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: 225700000X , with the licence number:  10920 , 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)

  • Identifier: 10920 . This is a "DORA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".