Provider Demographics
NPI:1306927231
Name:BOULDER VALLEY CENTER FOR DERMATOLOGY LLC
Entity type:Organization
Organization Name:BOULDER VALLEY CENTER FOR DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOEBEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-604-1444
Mailing Address - Street 1:1140 W SOUTH BOULDER RD
Mailing Address - Street 2:STE 202
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2854
Mailing Address - Country:US
Mailing Address - Phone:303-604-1444
Mailing Address - Fax:303-666-0911
Practice Address - Street 1:1140 W SOUTH BOULDER RD
Practice Address - Street 2:STE 202
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2854
Practice Address - Country:US
Practice Address - Phone:303-604-1444
Practice Address - Fax:303-666-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherTAX ID