=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528358132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGE HOLISTIC HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2011
-----------------------------------------------------
Last Update Date | 04/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1136 N LINCOLN AVE
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80537-4847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-667-7071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1136 N LINCOLN AVE
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80537-4847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-667-7071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/MEMBER
-----------------------------------------------------
Name | DEIRDRE G KOLOSKI
-----------------------------------------------------
Credential | ND, LAC
-----------------------------------------------------
Telephone | 970-667-7071
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 882
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------