Provider Demographics
NPI:1871517425
Name:MARY A WEAVER
Entity type:Organization
Organization Name:MARY A WEAVER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-215-5118
Mailing Address - Street 1:PO BOX 16724
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80402-6012
Mailing Address - Country:US
Mailing Address - Phone:303-215-5118
Mailing Address - Fax:303-215-5116
Practice Address - Street 1:15400 W 44TH AVE
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-7226
Practice Address - Country:US
Practice Address - Phone:303-215-5118
Practice Address - Fax:303-215-5116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherTAX ID NUMBER
CO1195960002Medicare NSC