Provider Demographics
NPI: | 1508555111 |
---|---|
Name: | TESTOSTERONE OPTIMIZATION CLINIC OF COLORADO |
Entity Type: | Organization |
Organization Name: | TESTOSTERONE OPTIMIZATION CLINIC OF COLORADO |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JAY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GRIFFIN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | NP-C |
Authorized Official - Phone: | 480-720-6347 |
Mailing Address - Street 1: | 1515 MAIN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | LONGMONT |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 80501-2864 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 720-899-9400 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1515 MAIN ST STE 15 |
Practice Address - Street 2: | |
Practice Address - City: | LONGMONT |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80501-2868 |
Practice Address - Country: | US |
Practice Address - Phone: | 720-899-9400 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-05-01 |
Last Update Date: | 2023-05-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QH0100X | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |