=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033724570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S URINARY AND BOWEL SOLUTIONS CLINIC AND CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2020
-----------------------------------------------------
Last Update Date | 09/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7501 VILLAGE SQUARE DR STE 207
-----------------------------------------------------
City | CASTLE PINES
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80108-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-955-4465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10799 W ALAMEDA AVE. PO BOX 260758
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-955-4465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER N MACK
-----------------------------------------------------
Credential | CPNP
-----------------------------------------------------
Telephone | 720-955-4465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------