1962685834 NPI number — OPTUMCARE ENDOSCOPY CENTER NEW MEXICO, LLC

Table of content: (NPI 1962685834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962685834 NPI number — OPTUMCARE ENDOSCOPY CENTER NEW MEXICO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUMCARE ENDOSCOPY CENTER NEW MEXICO, 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:
DAVITA MEDICAL ENDOSCOPY
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:
1962685834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 912680
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:
80291-4729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-262-7000
Provider Business Mailing Address Fax Number:
505-262-7652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5400 GIBSON BLVD SE
Provider Second Line Business Practice Location Address:
FLOOR 2; ELEVATOR C
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87108-4729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-262-7174
Provider Business Practice Location Address Fax Number:
505-262-3562
Provider Enumeration Date:
12/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LIETHEN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
952-205-6262

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  PENDING , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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