Basic Information
| Provider Information | |||||||||
| NPI: | 1952427049 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOULDERCENTRE FOR ORTHOPEDICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BOULDER ORTHOPEDICS PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 ALPINE AVE STE 211 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034171277 | ||||||||
| FaxNumber: | 3034171311 | ||||||||
| Practice Location | |||||||||
| Address1: | 4740 PEARL PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803013080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034492730 | ||||||||
| FaxNumber: | 3034495821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ICKES | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3034492730 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.