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General NPI Number Information
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NPI Number | 1518214345
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Entity Type | Organization
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Legal Business Name | DIABETES DYNAMICS
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Dates
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Enumeration Date | 08/10/2012
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Last Update Date | 08/10/2012
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Provider Practice Location Address
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Address Line | 9 RT. LADYBELLE PL BOX 5620
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City | EAGLE
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State | CO
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Zip | 81631-5620
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Country | US
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Telephone | 970-390-8311
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Fax | 970-328-5497
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Provider Business Mailing Address
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Address Line | BOX 5620 9 RT. LADYBELLE PL
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City | EAGLE
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State | CO
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Zip | 81631-5620
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Country | US
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Telephone | 970-390-8311
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Fax | 970-328-5497
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Authorized Official
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Title or Position | CERTIFIED DIABETES EDUCATOR
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Name | MS. THERESE ANTONELLI LANDIN
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Credential | MA, CDE
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Telephone | 970-390-8311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 09018253
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License Number State | CO
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