Healthcare Provider Details

I. General information

NPI: 1679732523
Provider Name (Legal Business Name): PBP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 S COLORADO BLVD # S-205
DENVER CO
80222-4000
US

IV. Provider business mailing address

PO BOX 1288
CROSBY TX
77532-1288
US

V. Phone/Fax

Practice location:
  • Phone: 281-462-1285
  • Fax:
Mailing address:
  • Phone: 281-462-1285
  • Fax: 281-462-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number41492
License Number StateCO

VIII. Authorized Official

Name: GARY GHISELLI
Title or Position: OWNER
Credential: MD
Phone: 281-462-1285