Organization
EXTREME SPORTS CAMP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. SALLIE BERNARD (EXECUTIVE DIRECTOR)
(970) 927-0433
Entity
Organization
Contact information
Practice address
23286 TWO RIVERS RD, SUITE 24-A, BASALT, CO 81621-9285
(970) 927-3143
Mailing address
23286 TWO RIVERS RD, SUITE 24-A, BASALT, CO 81621-9285
(970) 927-3143
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
1534517
CO
Other
Enumeration date
02/06/2012
Last updated
02/06/2012
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