1558526293 NPI number — ENDOSCOPY CENTER OF THE ROCKIES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558526293 NPI number — ENDOSCOPY CENTER OF THE ROCKIES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENDOSCOPY CENTER OF THE ROCKIES LLC
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:
ENDOSCOPY CENTER OF THE ROCKIES BOULDER
Provider Other Organization Name Type Code:
5
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:
1558526293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
382 S ARTHUR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80027-3094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-604-5000
Provider Business Mailing Address Fax Number:
720-890-0364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1755 48TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80301-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-604-5000
Provider Business Practice Location Address Fax Number:
720-890-0364
Provider Enumeration Date:
07/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MAHNKE
Authorized Official First Name:
DAUS
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD MEMBER
Authorized Official Telephone Number:
303-604-5000

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  1064 , 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: 95055011 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 490005424 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: EN64670 . This is a "BCBS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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