Provider Demographics
NPI:1669705042
Name:BOULDER PEAK FAMILY PRACTICE, INC.
Entity type:Organization
Organization Name:BOULDER PEAK FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:WISNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-543-1111
Mailing Address - Street 1:5330 MANHATTAN CIR # C-2
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4240
Mailing Address - Country:US
Mailing Address - Phone:303-543-1111
Mailing Address - Fax:303-543-1112
Practice Address - Street 1:5330 MANHATTAN CIR # C-2
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-4240
Practice Address - Country:US
Practice Address - Phone:303-543-1111
Practice Address - Fax:303-543-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty