Provider Demographics
NPI:1497225841
Name:AUTUMN SPIRIT PA, INC
Entity Type:Organization
Organization Name:AUTUMN SPIRIT PA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-920-7196
Mailing Address - Street 1:9436 HIDDEN PINES CT
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-4545
Mailing Address - Country:US
Mailing Address - Phone:941-920-7196
Mailing Address - Fax:
Practice Address - Street 1:10099 RIDGEGATE PKWY
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5531
Practice Address - Country:US
Practice Address - Phone:303-790-1800
Practice Address - Fax:303-790-1809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000152452Medicaid