MEDICARE: DR. KELLY PETER LETOURNEAU D.O.

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
1	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	43062	CO

General Provider Information

NPI Number	:	1285629741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY PETER LETOURNEAU D.O.

Provider Business Mailing Address
First Line	:	1360 S WADSWORTH BLVD
Second Line	:	208
City	:	LAKEWOOD
State	:	CO
Zip	:	80232-5415
Country	:	US
Telephone Number	:	303-980-1222
Fax Number	:	303-980-1119

Provider Business Practice Location Address
First Line	:	1360 S WADSWORTH BLVD
Second Line	:	208
City	:	LAKEWOOD
State	:	CO
Zip	:	80232-5415
Country	:	US
Telephone Number	:	303-980-1222
Fax Number	:	303-980-1119

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	07/08/2007

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