Healthcare Provider Details

I. General information

NPI: 1417162876
Provider Name (Legal Business Name): PEDIATRIC PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 BLAKE AVE STE 201
GLENWOOD SPRINGS CO
81601-4286
US

IV. Provider business mailing address

1905 BLAKE AVE STE 201
GLENWOOD SPRINGS CO
81601-4286
US

V. Phone/Fax

Practice location:
  • Phone: 970-947-9999
  • Fax: 970-947-9226
Mailing address:
  • Phone: 970-947-9999
  • Fax: 970-947-9226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: BONITA L WASLI
Title or Position: CFO
Credential:
Phone: 970-384-6605