Provider Demographics
NPI:1932157278
Name:COLORADO ATHLETIC CONDITIONING CLINIC PC
Entity Type:Organization
Organization Name:COLORADO ATHLETIC CONDITIONING CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-680-6121
Mailing Address - Street 1:PO BOX 173796
Mailing Address - Street 2:DEPT COL
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3796
Mailing Address - Country:US
Mailing Address - Phone:303-680-6121
Mailing Address - Fax:303-680-8627
Practice Address - Street 1:3451 S CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-5073
Practice Address - Country:US
Practice Address - Phone:303-680-6121
Practice Address - Fax:303-680-8627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCP4703Medicare ID - Type Unspecified