Provider Demographics
NPI:1881065837
Name:PONDEROSA NATURAL MEDICINE LLC
Entity type:Organization
Organization Name:PONDEROSA NATURAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:971-227-2613
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:IDLEDALE
Mailing Address - State:CO
Mailing Address - Zip Code:80453-0065
Mailing Address - Country:US
Mailing Address - Phone:971-227-2613
Mailing Address - Fax:
Practice Address - Street 1:244 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-4264
Practice Address - Country:US
Practice Address - Phone:971-227-2613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000106175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty