Provider Demographics
NPI:1467673897
Name:ECONOMIDIS, C KEITH (LAC,NCTMB,MSOM)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:KEITH
Last Name:ECONOMIDIS
Suffix:
Gender:M
Credentials:LAC,NCTMB,MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4728 ASHFIELD CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-4009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4728 ASHFIELD CT
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-4009
Practice Address - Country:US
Practice Address - Phone:303-817-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1236171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist