Provider Demographics
NPI:1265929814
Name:CONIFER PEDIATRICS
Entity type:Organization
Organization Name:CONIFER PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KUTALEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-674-6671
Mailing Address - Street 1:30960 STAGECOACH BLVD # W-120
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7902
Mailing Address - Country:US
Mailing Address - Phone:303-674-6671
Mailing Address - Fax:303-674-0031
Practice Address - Street 1:26719 PLEASANT PARK RD UNIT 120
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433-7753
Practice Address - Country:US
Practice Address - Phone:303-838-7337
Practice Address - Fax:303-816-6387
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN PEDIATRICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26133208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty