MEDICARE: AWAKEN IV

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	261Q00000X	Clinic/Center
2	261QI0500X	Infusion Therapy Clinic/Center

General Provider Information

NPI Number	:	1417810631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AWAKEN IV

Provider Business Mailing Address
First Line	:	5277 MANHATTAN CIR STE 260
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-8201
Country	:	US
Telephone Number	:	303-409-3690
Fax Number	:

Provider Business Practice Location Address
First Line	:	5277 MANHATTAN CIR STE 260
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-8201
Country	:	US
Telephone Number	:	303-409-3690
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NICHOLAS WINGO
Credential	:
Telephone Number	:	303-929-0946

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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