MEDICARE: BOULDER COMMUNITY HEALTH

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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1538225297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOULDER COMMUNITY HEALTH

Provider Business Mailing Address
First Line	:	5450 WESTERN AVE
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80301-2709
Country	:	US
Telephone Number	:	303-415-4340
Fax Number	:	303-604-4662

Provider Business Practice Location Address
First Line	:	1000 W SOUTH BOULDER RD STE 220
Second Line	:
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-2089
Country	:	US
Telephone Number	:	303-415-4340
Fax Number	:	303-604-4662

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CONNIE M LUCERO
Credential	:
Telephone Number	:	303-415-4770

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	04/22/2019

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