1306383039 NPI number — BOULDER COUNTY PRIMARY CARE AND REHAB

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 1306383039 NPI number — BOULDER COUNTY PRIMARY CARE AND REHAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOULDER COUNTY PRIMARY CARE AND REHAB
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:
1306383039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 INDIANA ST STE 320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDEN
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80401-5033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-842-0367
Provider Business Mailing Address Fax Number:
888-382-8131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 SUMMIT BLVD
Provider Second Line Business Practice Location Address:
#101
Provider Business Practice Location Address City Name:
BROOMFIELD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80021-8294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-842-0367
Provider Business Practice Location Address Fax Number:
888-382-8131
Provider Enumeration Date:
01/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ROCK
Authorized Official First Name:
GARRET
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
303-842-0367

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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