Provider Demographics
NPI:1720334899
Name:PEDIATRIC EFFECTIVE ELIMINATION PROGRAM CLINIC & CONSULTING, PC
Entity Type:Organization
Organization Name:PEDIATRIC EFFECTIVE ELIMINATION PROGRAM CLINIC & CONSULTING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MCGARRY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN RN CPNP CUNP
Authorized Official - Phone:720-771-1135
Mailing Address - Street 1:9249 S BROADWAY
Mailing Address - Street 2:#200-268
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-5690
Mailing Address - Country:US
Mailing Address - Phone:720-771-1135
Mailing Address - Fax:303-889-5247
Practice Address - Street 1:6179 S BALSAM WAY
Practice Address - Street 2:#205
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-3091
Practice Address - Country:US
Practice Address - Phone:720-771-1135
Practice Address - Fax:303-889-5247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO88483363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15729362Medicaid
CO522868Medicare PIN
COP23791Medicare UPIN