Healthcare Provider Details

I. General information

NPI: 1275131021
Provider Name (Legal Business Name): DENVER NEUROLOGICAL CLINIC PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9980 PARK MEADOWS DR STE 100
LONE TREE CO
80124-8404
US

IV. Provider business mailing address

9980 PARK MEADOWS DR STE 100
LONE TREE CO
80124-8404
US

V. Phone/Fax

Practice location:
  • Phone: 303-715-9024
  • Fax: 303-715-5020
Mailing address:
  • Phone: 303-715-9024
  • Fax: 303-715-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN MOON
Title or Position: OWNING PHYSICIAN
Credential:
Phone: 303-715-9024