Provider Demographics
NPI:1902275712
Name:INTEGRATIVE PEDIATRIC HEALTH CARE, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE PEDIATRIC HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RN, CPNP
Authorized Official - Phone:719-494-5123
Mailing Address - Street 1:3540 S POPLAR ST STE 202
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-1362
Mailing Address - Country:US
Mailing Address - Phone:720-442-3615
Mailing Address - Fax:720-870-3726
Practice Address - Street 1:3540 S POPLAR ST STE 202
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-1362
Practice Address - Country:US
Practice Address - Phone:720-442-3615
Practice Address - Fax:720-870-3726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10820051Medicaid