1750692265 NPI number — BETRU LLC

Table of content: (NPI 1750692265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750692265 NPI number — BETRU LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETRU 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:
BLUE CREEK INTEGRATIVE HEALTH
Provider Other Organization Name Type Code:
3
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:
1750692265
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7350 E 29TH AVE
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80238-2720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-573-7484
Provider Business Mailing Address Fax Number:
303-573-0994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7350 E 29TH AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80238-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-573-7484
Provider Business Practice Location Address Fax Number:
303-573-0994
Provider Enumeration Date:
06/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
303-573-7484

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  1170 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 4897 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: LNDMK . This is a "LANDMARK" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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