Basic Information
| Provider Information | |||||||||
| NPI: | 1720162084 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLORADO ATHLETIC CONDITIONING CLINIC LOWRY PROFESSIONAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CACC - LOWRY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 392977 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152514150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434068 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 QUEBEC ST STE 215 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802307144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033410369 | ||||||||
| FaxNumber: | 3033410866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REDFERN CATALDO | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4125672400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.