Healthcare Provider Details

I. General information

NPI: 1477039907
Provider Name (Legal Business Name): BOULDER BIOLOGICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 ARAPAHOE AVE STE 300
BOULDER CO
80303-1292
US

IV. Provider business mailing address

4745 ARAPAHOE AVE STE 300
BOULDER CO
80303-1292
US

V. Phone/Fax

Practice location:
  • Phone: 720-550-6175
  • Fax:
Mailing address:
  • Phone: 720-550-6175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number47816
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1922264175
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerINDIVIDUAL NPI NUMBER FOR JASON GLOWNEY

VIII. Authorized Official

Name: DR. JASON WELLS GLOWNEY
Title or Position: PRESIDENT
Credential: MD
Phone: 720-550-6175