Healthcare Provider Details

I. General information

NPI: 1619669793
Provider Name (Legal Business Name): CREATIVE CUSTOM FOOT ORTHOTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E YALE AVE STE 110
DENVER CO
80222-6930
US

IV. Provider business mailing address

5500 E YALE AVE STE 110
DENVER CO
80222-6930
US

V. Phone/Fax

Practice location:
  • Phone: 303-669-3771
  • Fax: 303-382-4600
Mailing address:
  • Phone: 303-669-3771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: ANDREW D. KELLY
Title or Position: OWNER/PRACTITIONER
Credential: BOCPD
Phone: 303-669-3771