1164675013 NPI number — MRS. GRETCHEN A BROECKER MS, RD, CDE

Table of content: DR. LAURA GOUGE ND (NPI 1588034680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164675013 NPI number — MRS. GRETCHEN A BROECKER MS, RD, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROECKER
Provider First Name:
GRETCHEN
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, RD, CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUEGE
Provider Other First Name:
GRETCHEN
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164675013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 PEAK ONE DR 390
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRISCO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-668-5584
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 PEAK ONE DRIVE
Provider Second Line Business Practice Location Address:
STE 260
Provider Business Practice Location Address City Name:
FRISCO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80443-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-668-5584
Provider Business Practice Location Address Fax Number:
970-262-2196
Provider Enumeration Date:
10/23/2008

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: 133NN1002X , with the licence number:  885627 , 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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