1548441611 NPI number — COLUMBINE RIDGE FAMILY MEDICINE P C

Table of content: (NPI 1548441611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548441611 NPI number — COLUMBINE RIDGE FAMILY MEDICINE P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBINE RIDGE FAMILY MEDICINE P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548441611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
965 PLATTE RIVER BLVD
Provider Second Line Business Mailing Address:
UNIT O, BLDG 1
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80601-4353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-655-9866
Provider Business Mailing Address Fax Number:
303-655-9869

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
965 PLATTE RIVER BLVD
Provider Second Line Business Practice Location Address:
UNIT O BLDG 1
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80601-4353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-655-9866
Provider Business Practice Location Address Fax Number:
303-655-9869
Provider Enumeration Date:
11/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
GUSTAVO
Authorized Official Title or Position:
SHARE HOLDER/ DOCTOR
Authorized Official Telephone Number:
303-875-8198

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  36368 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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