Healthcare Provider Details

I. General information

NPI: 1891989760
Provider Name (Legal Business Name): BOULDER VALLEY FOOT & ANKLE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4735 WALNUT ST STE C
BOULDER CO
80301-2553
US

IV. Provider business mailing address

4735 WALNUT ST STE C
BOULDER CO
80301-2553
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8900
  • Fax: 303-442-3140
Mailing address:
  • Phone: 303-443-8900
  • Fax: 303-442-3140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number478
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number StateCO

VIII. Authorized Official

Name: DONNA J COURTEMANCHE
Title or Position: MANAGER
Credential:
Phone: 303-443-8900