1336446475 NPI number — CRANIOFACIAL PAIN AND SLEEP CENTER

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 1336446475 NPI number — CRANIOFACIAL PAIN AND SLEEP CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRANIOFACIAL PAIN AND SLEEP CENTER
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:
1336446475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2627 REDWING RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80526-6321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-484-0250
Provider Business Mailing Address Fax Number:
970-484-1522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2627 REDWING RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80526-6321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-484-0250
Provider Business Practice Location Address Fax Number:
970-484-1522
Provider Enumeration Date:
02/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
HARVEY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
970-484-0250

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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