Provider Demographics
NPI:1245492248
Name:SCOTT BLUNK LAC LLC
Entity type:Organization
Organization Name:SCOTT BLUNK LAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:BLUNK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:970-223-4422
Mailing Address - Street 1:2601 S LEMAY AVE
Mailing Address - Street 2:SUITE 25
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2295
Mailing Address - Country:US
Mailing Address - Phone:970-223-4422
Mailing Address - Fax:970-223-9994
Practice Address - Street 1:2601 S LEMAY AVE
Practice Address - Street 2:SUITE 25
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2295
Practice Address - Country:US
Practice Address - Phone:970-223-4422
Practice Address - Fax:970-223-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO568261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty