Provider Demographics
NPI:1962821934
Name:BRASS BALLS TENDER HEART
Entity Type:Organization
Organization Name:BRASS BALLS TENDER HEART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHERN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:303-835-6886
Mailing Address - Street 1:1343 MILWAUKEE ST
Mailing Address - Street 2:APT. 1
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-2587
Mailing Address - Country:US
Mailing Address - Phone:303-835-6886
Mailing Address - Fax:
Practice Address - Street 1:1343 MILWAUKEE ST
Practice Address - Street 2:APT. 1
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-2587
Practice Address - Country:US
Practice Address - Phone:303-835-6886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0104032251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health