1215002167 NPI number — MRS. CAROLYN DURHAM LMT

Table of content: MRS. CAROLYN DURHAM LMT (NPI 1215002167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215002167 NPI number — MRS. CAROLYN DURHAM LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DURHAM
Provider First Name:
CAROLYN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
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:
1215002167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 N NEVADA AVE
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80903-1099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-229-9235
Provider Business Mailing Address Fax Number:
719-447-9262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 N NEVADA AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80903-1099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-229-9235
Provider Business Practice Location Address Fax Number:
719-447-9262
Provider Enumeration Date:
11/22/2006

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: 174400000X , with the licence number:  1335 , 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: 045617-00 . This is a "NCTMB #" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 1335 . This is a "STATE OF COLORADO, DEPT OF REGULARTORY AGENCIES, DIVISION OF REGISTRATIONS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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