Healthcare Provider Details

I. General information

NPI: 1265496194
Provider Name (Legal Business Name): KIMBERLY R DETWILER MS, LAT, ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 STADIUM DRIVE
BOULDER CO
80309-7059
US

IV. Provider business mailing address

1166 OPAL ST UNIT 102
BROOMFIELD CO
80020-7059
US

V. Phone/Fax

Practice location:
  • Phone: 512-230-6171
  • Fax:
Mailing address:
  • Phone: 512-230-6171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0001754
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: