Basic Information
Provider Information | |||||||||
NPI: | 1285848051 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREEN MOUNTAIN NEUROMONITORING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3464 S WILLOW ST | ||||||||
Address2: | 568 | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802314531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037552900 | ||||||||
FaxNumber: | 3037550404 | ||||||||
Practice Location | |||||||||
Address1: | 13547 W EXPOSITION DR | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 802283041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7202444498 | ||||||||
FaxNumber: | 7209630730 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRADBURN | ||||||||
AuthorizedOfficialFirstName: | JANICE | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7202444498 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 214 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 214 | 01 | CO | STATE LICENCSE | OTHER | 01092084 | 01 | CO | ASHA CERTIFICATION | OTHER |