Provider Demographics
NPI:1720162084
Name:COLORADO ATHLETIC CONDITIONING CLINIC LOWRY PROFESSIONAL LLC
Entity Type:Organization
Organization Name:COLORADO ATHLETIC CONDITIONING CLINIC LOWRY PROFESSIONAL LLC
Other - Org Name:CACC - LOWRY
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REDFERN CATALDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-567-2400
Mailing Address - Street 1:PO BOX 392977
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-4150
Mailing Address - Country:US
Mailing Address - Phone:724-343-4060
Mailing Address - Fax:724-343-4068
Practice Address - Street 1:200 QUEBEC ST STE 215
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-7144
Practice Address - Country:US
Practice Address - Phone:303-341-0369
Practice Address - Fax:303-341-0866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804320Medicare PIN