Healthcare Provider Details

I. General information

NPI: 1093315277
Provider Name (Legal Business Name): INNER RADIANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 DARLEY AVE STE 6
BOULDER CO
80305-6537
US

IV. Provider business mailing address

PO BOX 3413
BOULDER CO
80307-3413
US

V. Phone/Fax

Practice location:
  • Phone: 720-441-2850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MARK SWART
Title or Position: OWNER
Credential: MA
Phone: 719-480-1841