Healthcare Provider Details

I. General information

NPI: 1003233701
Provider Name (Legal Business Name): NICHOLAS BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 SOUTH RIDGE ST., SUITE 2B
BRECKENRIDGE CO
80424
US

IV. Provider business mailing address

PO BOX 1817
BRECKENRIDGE CO
80424-1817
US

V. Phone/Fax

Practice location:
  • Phone: 414-301-2057
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00202446
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: