MEDICARE: WIDE HORIZON, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282J00000X	Religious Nonmedical Health Care Institution	0107	CO

General Provider Information

NPI Number	:	1346244969
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIDE HORIZON, INC.

Provider Business Mailing Address
First Line	:	8900 W 38TH AVE
Second Line	:
City	:	WHEAT RIDGE
State	:	CO
Zip	:	80033-4204
Country	:	US
Telephone Number	:	303-424-4445
Fax Number	:	303-422-6373

Provider Business Practice Location Address
First Line	:	8900 W 38TH AVE
Second Line	:
City	:	WHEAT RIDGE
State	:	CO
Zip	:	80033-4204
Country	:	US
Telephone Number	:	303-424-4445
Fax Number	:	303-422-6373

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. D BRIAN BOETTIGER
Credential	:
Telephone Number	:	303-424-4445

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	08/22/2020

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