1902889967 NPI number — HENRY RAY LANDSGAARD

Table of content: HENRY RAY LANDSGAARD (NPI 1902889967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902889967 NPI number — HENRY RAY LANDSGAARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDSGAARD
Provider First Name:
HENRY
Provider Middle Name:
RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LANDSGAARD
Provider Other First Name:
HENRY
Provider Other Middle Name:
R.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1902889967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 912215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80291-2215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-306-7783
Provider Business Mailing Address Fax Number:
303-306-7753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1024 S LEMAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80524-3929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-495-7000
Provider Business Practice Location Address Fax Number:
303-306-7753
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  5101011929 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: DR.0055268 , 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: 3332953 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00065018 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3339927 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95937072 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3417756 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: HL011929 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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