Provider Demographics
NPI:1518214345
Name:DIABETES DYNAMICS
Entity Type:Organization
Organization Name:DIABETES DYNAMICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED DIABETES EDUCATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:ANTONELLI
Authorized Official - Last Name:LANDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CDE
Authorized Official - Phone:970-390-8311
Mailing Address - Street 1:BOX 5620
Mailing Address - Street 2:9 RT. LADYBELLE PL
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-5620
Mailing Address - Country:US
Mailing Address - Phone:970-390-8311
Mailing Address - Fax:970-328-5497
Practice Address - Street 1:9 RT. LADYBELLE PL
Practice Address - Street 2:BOX 5620
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631-5620
Practice Address - Country:US
Practice Address - Phone:970-390-8311
Practice Address - Fax:970-328-5497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO09018253261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center