1609031665 NPI number — METRO COMMUNITY PROVIDER NETWORK INC

Table of content: (NPI 1609031665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609031665 NPI number — METRO COMMUNITY PROVIDER NETWORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO COMMUNITY PROVIDER NETWORK 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:
PLATTE CANYON CLINIC
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:
1609031665
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3701 S BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80113-3611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-761-1977
Provider Business Mailing Address Fax Number:
303-761-2787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 COUNTY ROAD 43
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BAILEY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80421-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-838-1166
Provider Business Practice Location Address Fax Number:
303-838-1124
Provider Enumeration Date:
07/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
303-761-1977

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  18J548 , 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: 11033894 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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