1689714495 NPI number — COLORADO STATE INFUSION, INC.

Table of content: (NPI 1689714495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689714495 NPI number — COLORADO STATE INFUSION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO STATE INFUSION, 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:
COLORADO STATE INFUSION INC
Provider Other Organization Name Type Code:
3
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:
1689714495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17111 PRESTON RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75248-1229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-972-5888
Provider Business Mailing Address Fax Number:
866-491-5888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 N 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81501-2115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-243-3411
Provider Business Practice Location Address Fax Number:
970-243-3364
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRAYTON
Authorized Official First Name:
JOE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF STRATEGY OFFICER/EVP
Authorized Official Telephone Number:
972-588-1050

Provider Taxonomy Codes

  • Taxonomy code: 251F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PDO.0530000052 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2003295 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: PDO.0530000052 . This is a "DEPARTMENT OF REGULATORY AGENCIES" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 84152877 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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