Provider Demographics
NPI:1194409441
Name:BRO - BOULDER LLC
Entity type:Organization
Organization Name:BRO - BOULDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAZZOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-463-0567
Mailing Address - Street 1:5420 ARAPAHOE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1250
Mailing Address - Country:US
Mailing Address - Phone:720-463-0567
Mailing Address - Fax:303-494-5371
Practice Address - Street 1:5420 ARAPAHOE AVE STE A
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1250
Practice Address - Country:US
Practice Address - Phone:720-463-0567
Practice Address - Fax:303-494-5371
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREAKTHROUGH REGENERATIVE ORTHOPEDICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty