Healthcare Provider Details

I. General information

NPI: 1154893808
Provider Name (Legal Business Name): BRIAN SEGERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 TABLE MESA DR STE B
BOULDER CO
80305-4504
US

IV. Provider business mailing address

3865 CARLOCK DR
BOULDER CO
80305-6510
US

V. Phone/Fax

Practice location:
  • Phone: 303-499-9892
  • Fax:
Mailing address:
  • Phone: 303-472-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0003916
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: