=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174441703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEAK FORM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2026
-----------------------------------------------------
Last Update Date | 07/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8550 W 38TH AVE STE 100
-----------------------------------------------------
City | WHEAT RIDGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80033-4341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-655-9005
-----------------------------------------------------
Fax | 833-906-2577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1260 E 1ST AVE
-----------------------------------------------------
City | BROOMFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80020-3792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-655-9005
-----------------------------------------------------
Fax | 833-906-2577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | PATRICIA OCONNOR
-----------------------------------------------------
Credential | ADMINISTRATION
-----------------------------------------------------
Telephone | 303-655-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------