Basic Information
Provider Information | |||||||||
NPI: | 1093357907 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BOULDER COMMUNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4747 ARAPAHOE AVE | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803031131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034154700 | ||||||||
FaxNumber: | 3034154701 | ||||||||
Practice Location | |||||||||
Address1: | 4895 RIVERBEND RD | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803012640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034158890 | ||||||||
FaxNumber: | 3039383149 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2019 | ||||||||
LastUpdateDate: | 10/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEKAREK | ||||||||
AuthorizedOfficialFirstName: | JAY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REIMBURSEMENT SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3034154233 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BOULDER COMMUNITY HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
No ID Information.