Provider Demographics
NPI:1922291079
Name:COLORADO LIFESTYLE MEDICAL LLC
Entity Type:Organization
Organization Name:COLORADO LIFESTYLE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:AYDELOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-988-4875
Mailing Address - Street 1:11904 W CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2208
Mailing Address - Country:US
Mailing Address - Phone:303-988-4875
Mailing Address - Fax:
Practice Address - Street 1:11904 W CEDAR DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2208
Practice Address - Country:US
Practice Address - Phone:303-988-4875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42-40450-0000332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies