Healthcare Provider Details

I. General information

NPI: 1275630535
Provider Name (Legal Business Name): ROBERT M MASTELLER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 21ST AVE SUITE 41
LONGMONT CO
80501-1469
US

IV. Provider business mailing address

421 21ST AVE SUITE 41
LONGMONT CO
80501-1469
US

V. Phone/Fax

Practice location:
  • Phone: 303-772-9600
  • Fax: 303-772-9308
Mailing address:
  • Phone: 303-772-9600
  • Fax: 303-772-9308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1353
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: