Healthcare Provider Details

I. General information

NPI: 1003150335
Provider Name (Legal Business Name): ALICE BOUDREAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 STEELE ST
DENVER CO
80206-3945
US

IV. Provider business mailing address

860 STEELE ST
DENVER CO
80206-3945
US

V. Phone/Fax

Practice location:
  • Phone: 303-236-5945
  • Fax: 303-236-6072
Mailing address:
  • Phone: 303-236-5945
  • Fax: 303-236-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number35209
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: