Healthcare Provider Details

I. General information

NPI: 1114432903
Provider Name (Legal Business Name): BOULDER HEADACHE AND PAIN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5377 MANHATTAN CIR STE 200
BOULDER CO
80303-4345
US

IV. Provider business mailing address

5377 MANHATTAN CIR STE 200
BOULDER CO
80303-4345
US

V. Phone/Fax

Practice location:
  • Phone: 303-225-6625
  • Fax: 303-225-6626
Mailing address:
  • Phone: 303-225-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46517
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number46517
License Number StateCO

VIII. Authorized Official

Name: ALEX G REISH
Title or Position: OWNER
Credential: DO
Phone: 303-225-6625