Basic Information
Provider Information | |||||||||
NPI: | 1477755718 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THORNDIKE | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | LYNN HOLST | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOLST | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 500 ELDORADO BLVD # 6250 | ||||||||
Address2: |   | ||||||||
City: | BROOMFIELD | ||||||||
State: | CO | ||||||||
PostalCode: | 800213408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032720751 | ||||||||
FaxNumber: | 3033182488 | ||||||||
Practice Location | |||||||||
Address1: | 3814 E 120TH AVE | ||||||||
Address2: |   | ||||||||
City: | THORNTON | ||||||||
State: | CO | ||||||||
PostalCode: | 802331608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034522046 | ||||||||
FaxNumber: | 3032800942 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2007 | ||||||||
LastUpdateDate: | 01/16/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44567 | CO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 47627719 | 05 | CO |   | MEDICAID |