Provider Demographics
NPI:1679764005
Name:CARLSON, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 ELM ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220
Mailing Address - Country:US
Mailing Address - Phone:303-316-4971
Mailing Address - Fax:303-937-9646
Practice Address - Street 1:919 ELM ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220
Practice Address - Country:US
Practice Address - Phone:303-316-4971
Practice Address - Fax:303-937-9646
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04183471Medicaid
CO56122853Medicaid