Basic Information
| Provider Information | |||||||||
| NPI: | 1285017673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOULDER COMMUNITY HEALTH SPORTS MEDICINE IMAGING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOULDER COMMUNITY HEALTH SPORTS MEDICINE IMAGING LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9019 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803019019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039383295 | ||||||||
| FaxNumber: | 3034402435 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 STADIUM DR FL 2 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803090380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033159901 | ||||||||
| FaxNumber: | 3033159902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2015 | ||||||||
| LastUpdateDate: | 08/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | MUNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | V.P. AND CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3034157433 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.