Provider Demographics
NPI:1821321860
Name:SOURCE 1
Entity Type:Organization
Organization Name:SOURCE 1
Other - Org Name:FLATIRONS SPORTS MEDICINE OR SOURCE 1-DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-324-7674
Mailing Address - Street 1:3012 MICA CT
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-4548
Mailing Address - Country:US
Mailing Address - Phone:303-554-6699
Mailing Address - Fax:303-554-6700
Practice Address - Street 1:3550 LUTHERN PARKWAY
Practice Address - Street 2:SUITE 210
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033
Practice Address - Country:US
Practice Address - Phone:303-456-6051
Practice Address - Fax:303-456-6052
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOURCE 1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-09
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4274647332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1609109776OtherMAIN BUSINESS LOCATION NPI FOR SOURCE 1