Basic Information
| Provider Information | |||||||||
| NPI: | 1649879214 | ||||||||
| 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: | 101 ERIE PKWY STE 201H | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805164072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034422395 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2020 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
| 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: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.