MEDICARE: GROWING EXPERIENTIALLY MULTI-DISCIPLINARY SERVICE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	235Z00000X	Speech-Language Pathologist	CO
2	261QX0100X	Occupational Medicine Clinic/Center	CO
3	261QM1300X	Multi-Specialty Clinic/Center	CO

General Provider Information

NPI Number	:	1629252952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROWING EXPERIENTIALLY MULTI-DISCIPLINARY SERVICE

Provider Business Mailing Address
First Line	:	3443 S GALENA ST
Second Line	:	STE. 255
City	:	DENVER
State	:	CO
Zip	:	80231-5079
Country	:	US
Telephone Number	:	303-752-2977
Fax Number	:	303-752-2971

Provider Business Practice Location Address
First Line	:	3443 S GALENA ST
Second Line	:	STE. 255
City	:	DENVER
State	:	CO
Zip	:	80231-5079
Country	:	US
Telephone Number	:	303-752-2977
Fax Number	:	303-752-2971

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KENT VADELIUS
Credential	:
Telephone Number	:	303-752-2977

Provider Enumeration Date	:	12/21/2007
Last Update Date	:	12/21/2007

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