Provider Demographics
NPI:1952427049
Name:BOULDERCENTRE FOR ORTHOPEDICS
Entity type:Organization
Organization Name:BOULDERCENTRE FOR ORTHOPEDICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ICKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-449-2730
Mailing Address - Street 1:1000 ALPINE AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3411
Mailing Address - Country:US
Mailing Address - Phone:303-417-1277
Mailing Address - Fax:303-417-1311
Practice Address - Street 1:4740 PEARL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3080
Practice Address - Country:US
Practice Address - Phone:303-449-2730
Practice Address - Fax:303-449-5821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherTIN