1174958326 NPI number — BROOKE A SCURLOCK NP

Table of content: RAINA HALASA (NPI 1427659663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174958326 NPI number — BROOKE A SCURLOCK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCURLOCK
Provider First Name:
BROOKE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174958326
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 ROCKY MOUNTAIN AVE STE 2200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80538-9004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-699-1009
Provider Business Mailing Address Fax Number:
970-669-0400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 ROCKY MOUNTAIN AVE STE 2200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVELAND
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80538-9004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-699-1009
Provider Business Practice Location Address Fax Number:
970-669-0400
Provider Enumeration Date:
09/06/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  17894 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: C-APN.0001859-C-NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9000180048 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".