1972683035 NPI number — FRONT RANGE ENDOCRINOLOGY PC

Table of content: JARED MATTHEW WALKER C.P.M. (NPI 1114758786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972683035 NPI number — FRONT RANGE ENDOCRINOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRONT RANGE ENDOCRINOLOGY PC
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:
1972683035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5753 WINDRIDGE PT
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:
80908-1423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-495-4120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1625 MEDICAL CENTER PT
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80907-8731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-630-3276
Provider Business Practice Location Address Fax Number:
719-635-4377
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOOK
Authorized Official First Name:
LORI
Authorized Official Middle Name:
DAVIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
719-359-1223

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  42508 , 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: 12251321 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1750370003 . This is a "INDIVIDUAL NPI NUMBER" identifier . This identifiers is of the category "OTHER".




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