Healthcare Provider Details

I. General information

NPI: 1194409441
Provider Name (Legal Business Name): BRO - BOULDER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 ARAPAHOE AVE STE A
BOULDER CO
80303-1250
US

IV. Provider business mailing address

5420 ARAPAHOE AVE STE A
BOULDER CO
80303-1250
US

V. Phone/Fax

Practice location:
  • Phone: 720-463-0567
  • Fax: 303-494-5371
Mailing address:
  • Phone: 720-463-0567
  • Fax: 303-494-5371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY J MAZZOLA
Title or Position: SOLE OWNER
Credential: MD
Phone: 720-463-0567