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NPI Code Detail

MEDICARE: MORANDA LYNN BOLES RD

MEDICARE: MORANDA LYNN BOLES RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian1099702CO

General Provider Information

NPI Number : 1245754910
Entity Type Code : Individual
Provider Name (Legal Business Name) : MORANDA LYNN BOLES RD
Provider Business Mailing Address
First Line : 11820 DESTINATION DR
Second Line :
City : BROOMFIELD
State : CO
Zip : 80021-2518
Country : US
Telephone Number : 303-460-6065
Fax Number :
Provider Business Practice Location Address
First Line : 11820 DESTINATION DR
Second Line :
City : BROOMFIELD
State : CO
Zip : 80021-2518
Country : US
Telephone Number : 303-460-6065
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/03/2017
Last Update Date : 07/21/2022

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Directions to “ MORANDA LYNN BOLES RD” Practice Location

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