Provider Demographics
NPI:1528157526
Name:ASPEN LEAF SPORTS MEDICINE AND REHABILITATION PC
Entity type:Organization
Organization Name:ASPEN LEAF SPORTS MEDICINE AND REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEHRS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-349-5269
Mailing Address - Street 1:4861 EARLE CIR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-4122
Mailing Address - Country:US
Mailing Address - Phone:303-349-5269
Mailing Address - Fax:720-479-8320
Practice Address - Street 1:4861 EARLE CIR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-4122
Practice Address - Country:US
Practice Address - Phone:303-349-5269
Practice Address - Fax:720-479-8320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C804868Medicare PIN