Healthcare Provider Details

I. General information

NPI: 1902275712
Provider Name (Legal Business Name): INTEGRATIVE PEDIATRIC HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 S POPLAR ST STE 202
DENVER CO
80237-1362
US

IV. Provider business mailing address

3540 S POPLAR ST STE 202
DENVER CO
80237-1362
US

V. Phone/Fax

Practice location:
  • Phone: 720-442-3615
  • Fax: 720-870-3726
Mailing address:
  • Phone: 720-442-3615
  • Fax: 720-870-3726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER GAUGHAN
Title or Position: MEMBER, PRACTITIONER
Credential: MS, RN, CPNP
Phone: 719-494-5123