Healthcare Provider Details

I. General information

NPI: 1548555949
Provider Name (Legal Business Name): BONNIE J ROTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10065 E HARVARD AVE STE 400
DENVER CO
80231-5943
US

IV. Provider business mailing address

902 S MCKINLEY AVE
FORT LUPTON CO
80621-1283
US

V. Phone/Fax

Practice location:
  • Phone: 303-614-1500
  • Fax:
Mailing address:
  • Phone: 303-717-0919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number96793
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: