Provider Demographics
NPI:1184137762
Name:NORTHERN COLORADO FOOT AND ANKLE CLINICS PROFESSIONAL LLC
Entity type:Organization
Organization Name:NORTHERN COLORADO FOOT AND ANKLE CLINICS PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-389-2203
Mailing Address - Street 1:3306 ABBEY RD UNIT 713
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-8623
Mailing Address - Country:US
Mailing Address - Phone:417-389-2203
Mailing Address - Fax:
Practice Address - Street 1:12201 PECOS ST STE 400
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-3994
Practice Address - Country:US
Practice Address - Phone:303-469-9292
Practice Address - Fax:303-438-8951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000803213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty