Provider Demographics
NPI:1265432579
Name:1ST ALLERGY & ASTHMA
Entity type:Organization
Organization Name:1ST ALLERGY & ASTHMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:720-929-8300
Mailing Address - Street 1:2136 E 104TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-4313
Mailing Address - Country:US
Mailing Address - Phone:720-929-8300
Mailing Address - Fax:720-929-8444
Practice Address - Street 1:2136 E 104TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-4313
Practice Address - Country:US
Practice Address - Phone:720-929-8300
Practice Address - Fax:720-929-8444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO321302080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01321306Medicaid
CO01321306Medicaid
COCD4638Medicare ID - Type Unspecified