1568117901 NPI number — PEAK BRAIN PERFORMANCE CENTERS

Table of content: DR. ROBERT NELSON SORENSON D.D.S. (NPI 1982775078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568117901 NPI number — PEAK BRAIN PERFORMANCE CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEAK BRAIN PERFORMANCE CENTERS
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:
1568117901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4740 FINTRIDGE DR. SUITE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80918-4253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-208-4314
Provider Business Mailing Address Fax Number:
719-960-2192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4740 FINTRIDGE DR. SUITE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80918-4253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-208-4314
Provider Business Practice Location Address Fax Number:
719-960-2192
Provider Enumeration Date:
02/15/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SHEM
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
ARTHUR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-208-4314

Provider Taxonomy Codes

  • Taxonomy code: 111NN0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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