MEDICARE: COLORADO LASER CLINIC INC

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	208200000X	Plastic Surgery Physician	27602	CO

General Provider Information

NPI Number	:	1740623081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO LASER CLINIC INC

Provider Business Mailing Address
First Line	:	1985 DOMINION WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-1476
Country	:	US
Telephone Number	:	719-596-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1985 DOMINION WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-1476
Country	:	US
Telephone Number	:	719-596-4000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT T MOTAZEDI
Credential	:	M.D.
Telephone Number	:	719-596-4000

Provider Enumeration Date	:	04/16/2013
Last Update Date	:	04/16/2013

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