=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477034502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYOGAM COLORADO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2018
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2216 HOFFMAN DR STE B
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-4397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-667-9901
-----------------------------------------------------
Fax | 970-461-7800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2216 HOFFMAN DR STE B
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-4397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-667-9901
-----------------------------------------------------
Fax | 970-461-7800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ELIZABETH CAIRO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 970-667-9901
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VE0102X
-----------------------------------------------------
Taxonomy Name | Reproductive Endocrinology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------