Healthcare Provider Details

I. General information

NPI: 1972093888
Provider Name (Legal Business Name): MARINA LANE MS RD CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N GRANT ST STE R
DENVER CO
80203-1859
US

IV. Provider business mailing address

1500 N GRANT ST STE R
DENVER CO
80203-1859
US

V. Phone/Fax

Practice location:
  • Phone: 720-680-2940
  • Fax:
Mailing address:
  • Phone: 720-680-2940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number009597
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number009597
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number282242
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: