Healthcare Provider Details

I. General information

NPI: 1417169921
Provider Name (Legal Business Name): INTEGRAL THERAPEUTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 MANHATTAN DR STE 101
BOULDER CO
80303
US

IV. Provider business mailing address

75 MANHATTAN DR STE 101
BOULDER CO
80303
US

V. Phone/Fax

Practice location:
  • Phone: 303-819-4617
  • Fax:
Mailing address:
  • Phone: 303-819-4617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number7006
License Number StateCO

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MRS. ANDREA TAPIA STAMM
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 303-819-4617