Healthcare Provider Details

I. General information

NPI: 1114284346
Provider Name (Legal Business Name): MS. TESS EKLUND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 CENTER GREEN DR STE 150
BOULDER CO
80301-2364
US

IV. Provider business mailing address

10255 DOVER ST APT 432
WESTMINSTER CO
80021-3986
US

V. Phone/Fax

Practice location:
  • Phone: 303-449-8807
  • Fax:
Mailing address:
  • Phone: 970-376-1729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number1530
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier1530
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerACTIVE SURGICAL ASSISTANT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: