Provider Demographics
NPI:1700584414
Name:IV NUTRITION OF WASH PARK
Entity Type:Organization
Organization Name:IV NUTRITION OF WASH PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:TERRILL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:172-072-7350
Mailing Address - Street 1:1211 E ALAMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2420
Mailing Address - Country:US
Mailing Address - Phone:720-259-4404
Mailing Address - Fax:
Practice Address - Street 1:1211 E ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-2420
Practice Address - Country:US
Practice Address - Phone:720-259-4404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO682Other682