=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720334899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC EFFECTIVE ELIMINATION PROGRAM CLINIC & CONSULTING, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2012
-----------------------------------------------------
Last Update Date | 09/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6179 S BALSAM WAY #205
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80123-3091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-771-1135
-----------------------------------------------------
Fax | 303-889-5247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9249 S BROADWAY #200-268
-----------------------------------------------------
City | HIGHLANDS RANCH
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80129-5690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-771-1135
-----------------------------------------------------
Fax | 303-889-5247
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, PRESIDENT
-----------------------------------------------------
Name | MICHELLE LYNN MCGARRY
-----------------------------------------------------
Credential | MSN RN CPNP CUNP
-----------------------------------------------------
Telephone | 720-771-1135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 88483
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------