Provider Demographics
NPI:1871262253
Name:STACY GREEN ENTERPRISES, LLC
Entity Type:Organization
Organization Name:STACY GREEN ENTERPRISES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-717-2521
Mailing Address - Street 1:3985 WONDERLAND HILL AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-1038
Mailing Address - Country:US
Mailing Address - Phone:303-717-2521
Mailing Address - Fax:
Practice Address - Street 1:3985 WONDERLAND HILL AVE STE 107
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1038
Practice Address - Country:US
Practice Address - Phone:303-717-2521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service