1306100656 NPI number — MS. STACEY LEIGH GRUBER P.C., M.S.LAC

Table of content: MS. STACEY LEIGH GRUBER P.C., M.S.LAC (NPI 1306100656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306100656 NPI number — MS. STACEY LEIGH GRUBER P.C., M.S.LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRUBER
Provider First Name:
STACEY
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.C., M.S.LAC
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:
1306100656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 S HOWES ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80521-2871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-472-5846
Provider Business Mailing Address Fax Number:
970-472-5071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 S HOWES ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80521-2871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-472-5846
Provider Business Practice Location Address Fax Number:
970-472-5071
Provider Enumeration Date:
07/02/2012

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: 171100000X , with the licence number:  1026 , 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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