MEDICARE: MADE LLC

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	174400000X	Specialist

General Provider Information

NPI Number	:	1922420207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADE LLC

Provider Business Mailing Address
First Line	:	9758 LAREDO ST UNIT 38C
Second Line	:
City	:	COMMERCE CITY
State	:	CO
Zip	:	80022-9827
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9758 LAREDO ST UNIT 38C
Second Line	:
City	:	COMMERCE CITY
State	:	CO
Zip	:	80022-9827
Country	:	US
Telephone Number	:	281-324-5660
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAWRENCE DAVIS
Credential	:
Telephone Number	:	281-324-5660

Provider Enumeration Date	:	01/06/2014
Last Update Date	:	01/06/2014

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