Healthcare Provider Details

I. General information

NPI: 1790850055
Provider Name (Legal Business Name): KAISER FOUNDATION HEALTH PLAN OF COLORADO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 MOHAWK DR
BOULDER CO
80303-3712
US

IV. Provider business mailing address

580 MOHAWK DR
BOULDER CO
80303-3712
US

V. Phone/Fax

Practice location:
  • Phone: 970-554-5020
  • Fax: 970-554-5010
Mailing address:
  • Phone: 970-554-5020
  • Fax: 970-554-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number90000041
License Number StateCO

VIII. Authorized Official

Name: DENESE CLARK
Title or Position: REGIONAL ADMINISTRATOR
Credential:
Phone: 303-326-6717