Provider Demographics
NPI:1134513351
Name:PLANET T HORMONE REPLACEMENT CENTER
Entity Type:Organization
Organization Name:PLANET T HORMONE REPLACEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADBURRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-237-8609
Mailing Address - Street 1:2631 W COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-3024
Mailing Address - Country:US
Mailing Address - Phone:719-237-8609
Mailing Address - Fax:
Practice Address - Street 1:2631 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3024
Practice Address - Country:US
Practice Address - Phone:719-237-8609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0045073207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty