=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710368303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKY MOUNTAIN HORMONE AND WEIGHT LOSS CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2015
-----------------------------------------------------
Last Update Date | 06/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6950 E BELLEVIEW AVE SUITE 102
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-476-3366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6950 E BELLEVIEW AVE SUITE 102
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-476-3366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TANGI TERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-476-3366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133NN1002X
-----------------------------------------------------
Taxonomy Name | Nutrition Education Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------