=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508555111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TESTOSTERONE OPTIMIZATION CLINIC OF COLORADO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2023
-----------------------------------------------------
Last Update Date | 05/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 MAIN ST STE 15
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-2868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-899-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 MAIN ST
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-2864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-899-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAY GRIFFIN
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 480-720-6347
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------