1114316627 NPI number — YAH ORTHO INC

Table of content: (NPI 1114316627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114316627 NPI number — YAH ORTHO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YAH ORTHO INC
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:
1114316627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2603 VINEWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81005-3370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-564-6464
Provider Business Mailing Address Fax Number:
719-564-1888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3821 W PUEBLO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81005-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
197-564-6467
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BIELECKI
Authorized Official First Name:
PAWEL
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
720-435-1550

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  8809 , 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)

  • Identifier: 31571336 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".