Provider Demographics
NPI:1861035412
Name:EMBRACEKIDS V A PROFESSIONAL LLC
Entity Type:Organization
Organization Name:EMBRACEKIDS V A PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-224-8171
Mailing Address - Street 1:5865 E POWERS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-1545
Mailing Address - Country:US
Mailing Address - Phone:303-907-7978
Mailing Address - Fax:
Practice Address - Street 1:5375 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80212-7058
Practice Address - Country:US
Practice Address - Phone:303-476-6292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental