Provider Demographics
NPI:1134450539
Name:FORT COLLINS MEDI-SPA
Entity type:Organization
Organization Name:FORT COLLINS MEDI-SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-204-0400
Mailing Address - Street 1:4103 BOARDWALK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5931
Mailing Address - Country:US
Mailing Address - Phone:970-204-0400
Mailing Address - Fax:970-377-1082
Practice Address - Street 1:4103 BOARDWALK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5931
Practice Address - Country:US
Practice Address - Phone:970-204-0400
Practice Address - Fax:970-377-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Multi-Specialty
No173C00000XOther Service ProvidersReflexologistGroup - Multi-Specialty