=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801154679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNE JEANNE BOURGEAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2012
-----------------------------------------------------
Last Update Date | 04/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1148 WEST DILLON ROAD SUITE 1
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-554-1600
-----------------------------------------------------
Fax | 720-328-8188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1148 WEST DILLON ROAD SUITE 1
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-554-1600
-----------------------------------------------------
Fax | 720-328-8188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 12554
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------