Provider Demographics
NPI:1952522997
Name:BOULDER VALLEY ASTHMA & ALLERGY CLINICS, PC
Entity Type:Organization
Organization Name:BOULDER VALLEY ASTHMA & ALLERGY CLINICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MENICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-234-1067
Mailing Address - Street 1:1746 COLE BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3208
Mailing Address - Country:US
Mailing Address - Phone:303-234-1067
Mailing Address - Fax:303-232-2967
Practice Address - Street 1:3950 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1104
Practice Address - Country:US
Practice Address - Phone:303-234-1067
Practice Address - Fax:303-232-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04006102Medicaid
COC803573Medicare PIN