=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275635773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTY JOELLE STATES OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 S COLORADO BLVD STE 206 BLDG B
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80222-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-753-6611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1826 S LINDEN WAY
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80224-2161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-753-6611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204C00000X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
-----------------------------------------------------
License Number | 00000
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------