=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134968092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHONE CLINIC SERVICES - PEDIATRIC SPECIALTIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2024
-----------------------------------------------------
Last Update Date | 05/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 BANNOCK ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80204-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-602-2718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 HEALTH PARK DR
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-4692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-602-2718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | NICHOLAS F WADLINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-401-9807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XP3100X
-----------------------------------------------------
Taxonomy Name | Pediatric Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------