Healthcare Provider Details

I. General information

NPI: 1831206770
Provider Name (Legal Business Name): BOULDER SPORT AND SPINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 TABLE MESA DR STE 201
BOULDER CO
80305-5850
US

IV. Provider business mailing address

3400 TABLE MESA DR STE 201
BOULDER CO
80305-5850
US

V. Phone/Fax

Practice location:
  • Phone: 303-494-0944
  • Fax: 303-494-8678
Mailing address:
  • Phone: 303-494-0944
  • Fax: 303-494-8678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3053
License Number StateCO

VIII. Authorized Official

Name: LARRY ERIC FRIEDER
Title or Position: OWNER
Credential: DC, CCSP
Phone: 303-494-0944