Healthcare Provider Details

I. General information

NPI: 1447254313
Provider Name (Legal Business Name): BOULDER COUNTY PUBLIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3482 BROADWAY ST
BOULDER CO
80304-1824
US

IV. Provider business mailing address

3450 BROADWAY ST
BOULDER CO
80304-1824
US

V. Phone/Fax

Practice location:
  • Phone: 303-413-7500
  • Fax: 303-441-1452
Mailing address:
  • Phone: 303-441-1100
  • Fax: 303-441-1452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number1001
License Number StateCO

VII. Legacy identifiers

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

# 1
Identifier00572543
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: MS. STEPHANIE MARTZ
Title or Position: DIRECTOR OF ADMINISTRATIVE SERVICES
Credential:
Phone: 303-441-1142