Healthcare Provider Details

I. General information

NPI: 1982034237
Provider Name (Legal Business Name): AMANDA NIEDERHAUSER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2013
Last Update Date: 11/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 DOMINION WAY
COLORADO SPRINGS CO
80918-1465
US

IV. Provider business mailing address

9070 CHARITY DR
COLORADO SPRINGS CO
80920-7368
US

V. Phone/Fax

Practice location:
  • Phone: 719-200-6832
  • Fax:
Mailing address:
  • Phone: 719-200-6832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberMT.0014165
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: