1679909519 NPI number — MRS. SOMA OLISOA GLICK LIC.AC, D.O.M.

Table of content: MRS. SOMA OLISOA GLICK LIC.AC, D.O.M. (NPI 1679909519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679909519 NPI number — MRS. SOMA OLISOA GLICK LIC.AC, D.O.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLICK
Provider First Name:
SOMA
Provider Middle Name:
OLISOA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LIC.AC, D.O.M.
Provider Gender Code:
F

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:
1679909519
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1067 ORANGE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80304-0730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-931-6289
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6620 GUNPARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80301-3339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-581-9955
Provider Business Practice Location Address Fax Number:
303-581-9944
Provider Enumeration Date:
09/24/2013

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: 171100000X , with the licence number:  466 , 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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