Basic Information
| Provider Information | |||||||||
| NPI: | 1679002356 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCKY MOUNTAIN ANAPLASTOLOGY INC | ||||||||
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| OtherOrganizationName: | PROSTHETIC ILLUSIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3405 S YARROW ST UNIT C | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802274901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039738482 | ||||||||
| FaxNumber: | 3039738468 | ||||||||
| Practice Location | |||||||||
| Address1: | 3405 S YARROW ST UNIT C | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802274901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039738482 | ||||||||
| FaxNumber: | 3039738468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LILLO | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3039738482 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 156FX1700X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Ocularist | 224900000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Mastectomy Fitter | 156FX1800X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 08835233 | 05 | CO | MEDICAID |