Provider Demographics
NPI:1891989760
Name:BOULDER VALLEY FOOT & ANKLE CLINIC PC
Entity Type:Organization
Organization Name:BOULDER VALLEY FOOT & ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:COURTEMANCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-443-8900
Mailing Address - Street 1:4735 WALNUT ST STE C
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2553
Mailing Address - Country:US
Mailing Address - Phone:303-443-8900
Mailing Address - Fax:303-442-3140
Practice Address - Street 1:4735 WALNUT ST STE C
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2553
Practice Address - Country:US
Practice Address - Phone:303-443-8900
Practice Address - Fax:303-442-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO478213ES0103X
CO213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCA3903Medicare PIN