Provider Demographics
NPI:1316464076
Name:BOULDER VALLEY IOM, LLC
Entity type:Organization
Organization Name:BOULDER VALLEY IOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-316-9902
Mailing Address - Street 1:5023 W 120TH AVE
Mailing Address - Street 2:PO BOX 236
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-5606
Mailing Address - Country:US
Mailing Address - Phone:303-803-4004
Mailing Address - Fax:303-302-1591
Practice Address - Street 1:3492 W 155TH AVE
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-4100
Practice Address - Country:US
Practice Address - Phone:202-316-9902
Practice Address - Fax:303-302-1591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty