1154128015 NPI number — IMMERSIV HEALTH OF COLORADO, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154128015 NPI number — IMMERSIV HEALTH OF COLORADO, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMMERSIV HEALTH OF COLORADO, PLLC
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:
6
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:
1154128015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
382 NE 191ST ST STE 93920
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33179-3899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-551-6650
Provider Business Mailing Address Fax Number:
855-694-4656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9777 PYRAMID CT STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80112-6009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-551-6650
Provider Business Practice Location Address Fax Number:
855-694-4656
Provider Enumeration Date:
02/27/2025

Additional Information

Authorized Official

Authorized Official Last Name:
HAN
Authorized Official First Name:
SON
Authorized Official Middle Name:
HEE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
877-551-6650

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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