Basic Information
| Provider Information | |||||||||
| NPI: | 1497341754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOULDER PLASTIC SURGERY PROF LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7643 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
| FaxNumber: | 9703422093 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 BALSAM AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034402273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2020 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE CONTACT | ||||||||
| AuthorizedOfficialTelephone: | 3034432277 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.