Healthcare Provider Details

I. General information

NPI: 1831047331
Provider Name (Legal Business Name): BETHANY ALAINE MATHIS MSPO, CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2026
Last Update Date: 03/19/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCARDO ST SUITE 203
DURANGO CO
81301
US

IV. Provider business mailing address

1415 HIGH FLUME DR
DURANGO CO
81303-8410
US

V. Phone/Fax

Practice location:
  • Phone: 505-415-1519
  • Fax:
Mailing address:
  • Phone: 505-415-1519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO05189
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: