Provider Demographics
NPI:1346569159
Name:COLORADO FUNCTIONAL MEDICINE
Entity Type:Organization
Organization Name:COLORADO FUNCTIONAL MEDICINE
Other - Org Name:TRUE LIFE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-686-7776
Mailing Address - Street 1:403 S BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-3154
Mailing Address - Country:US
Mailing Address - Phone:713-686-7776
Mailing Address - Fax:719-355-1927
Practice Address - Street 1:403 S BALDWIN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-3154
Practice Address - Country:US
Practice Address - Phone:713-686-7776
Practice Address - Fax:719-355-1926
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLORADO FUNCTIONAL MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-19
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1124011507OtherNPI
CO71189513OtherNPI