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General NPI Number Information
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NPI Number | 1396190831
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Entity Type | Organization
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Legal Business Name | IANNOTTI LIFESTYLE CLINIC PC
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Dates
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Enumeration Date | 05/03/2016
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Last Update Date | 07/26/2016
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Provider Practice Location Address
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Address Line | 150 OLD LARAMIE TRL E SUITE 210
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City | LAFAYETTE
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State | CO
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Zip | 80026-7018
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Country | US
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Telephone | 720-773-1352
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Fax | 303-604-6958
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Provider Business Mailing Address
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Address Line | 150 OLD LARAMIE TRL E SUITE 210
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City | LAFAYETTE
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State | CO
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Zip | 80026-7018
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Country | US
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Telephone | 720-773-1352
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Fax | 303-604-6958
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Authorized Official
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Title or Position | PHYSICIAN/ OWNER
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Name | MICHAEL ROBERT IANNOTTI
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Credential | MD
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Telephone | 720-773-1352
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DR.0039567
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License Number State | CO
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