1902350788 NPI number — COLLABORATIVE SERVICE FOR CHANGE PC

Table of content: HUN K. LEE M.D. (NPI 1659413706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902350788 NPI number — COLLABORATIVE SERVICE FOR CHANGE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLLABORATIVE SERVICE FOR CHANGE PC
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:
1902350788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2480 W 26TH AVE
Provider Second Line Business Mailing Address:
SUITE 130B
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80211-5309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-433-0188
Provider Business Mailing Address Fax Number:
303-433-6145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2480 W 26TH AVE
Provider Second Line Business Practice Location Address:
SUITE 130B
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80211-5309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-433-0188
Provider Business Practice Location Address Fax Number:
303-433-6145
Provider Enumeration Date:
08/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KISICKI
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
303-433-0188

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  992298 , 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: 42427851 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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