Basic Information
Provider Information | |||||||||
NPI: | 1861035412 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMBRACEKIDS V A PROFESSIONAL LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5865 E POWERS AVE | ||||||||
Address2: |   | ||||||||
City: | GREENWOOD VILLAGE | ||||||||
State: | CO | ||||||||
PostalCode: | 801111545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039077978 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5375 W 38TH AVE | ||||||||
Address2: |   | ||||||||
City: | WHEAT RIDGE | ||||||||
State: | CO | ||||||||
PostalCode: | 802127058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034766292 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2019 | ||||||||
LastUpdateDate: | 10/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NIEBERG | ||||||||
AuthorizedOfficialFirstName: | OWEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 9172248171 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.