MEDICARE: CHELSEA MARIE IDEKER MSOTR/L

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	171W00000X	Contractor	2687	CO

General Provider Information

NPI Number	:	1689983595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHELSEA MARIE IDEKER MSOTR/L

Provider Business Mailing Address
First Line	:	1821 S PEARL ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80210-3136
Country	:	US
Telephone Number	:	970-690-7204
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 S PEARL ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80210-3136
Country	:	US
Telephone Number	:	970-690-7204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2010
Last Update Date	:	11/02/2020

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