Healthcare Provider Details

I. General information

NPI: 1902418965
Provider Name (Legal Business Name): KLARISANA PHYSICIAN SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9195 GRANT ST STE 130
THORNTON CO
80229-4348
US

IV. Provider business mailing address

PO BOX 736403
DALLAS TX
75373-6403
US

V. Phone/Fax

Practice location:
  • Phone: 303-535-7548
  • Fax:
Mailing address:
  • Phone: 303-535-7548
  • Fax: 888-504-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CARL JOHN BONNETT
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 303-535-7548