1871716928 NPI number — BROOKE LYNN GLAZA MPT

Table of content: BROOKE LYNN GLAZA MPT (NPI 1871716928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871716928 NPI number — BROOKE LYNN GLAZA MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLAZA
Provider First Name:
BROOKE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
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:
1871716928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 SUPERIOR DR
Provider Second Line Business Mailing Address:
STE 225
Provider Business Mailing Address City Name:
SUPERIOR
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80027-8661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-546-9158
Provider Business Mailing Address Fax Number:
303-546-9107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 NICKEL ST STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOMFIELD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80020-2097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-460-9129
Provider Business Practice Location Address Fax Number:
303-469-2324
Provider Enumeration Date:
04/10/2007

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: 225100000X , with the licence number:  9918 , 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)