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General NPI Number Information
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NPI Number | 1184210312
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Entity Type | Organization
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Legal Business Name | BOULDER VALLEY GASTROENTEROLOGY INC.
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Dates
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Enumeration Date | 12/11/2020
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Last Update Date | 12/11/2020
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Provider Practice Location Address
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Address Line | 1551 PROFESSIONAL LN UNIT 290
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City | LONGMONT
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State | CO
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Zip | 80501-6970
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Country | US
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Telephone | 303-604-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 382 S ARTHUR AVE
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City | LOUISVILLE
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State | CO
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Zip | 80027-3094
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MD
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Name | DAUS MAHNKE
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Credential |
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Telephone | 303-604-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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