Basic Information
| Provider Information | |||||||||
| NPI: | 1942233457 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOULDER SPINE CENTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MINIMALLY INVASIVE SPINE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 300 EXEMPLA CIR STE 130 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800263484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035392533 | ||||||||
| FaxNumber: | 3035392534 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 EXEMPLA CIR STE 130 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800263484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035392533 | ||||||||
| FaxNumber: | 3035392534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALDOCK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | BOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER AND AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6152345900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QA1903X | 16Y773 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.