1972712701 NPI number — PRINCETON HOUSE

Table of content: (NPI 1972712701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972712701 NPI number — PRINCETON HOUSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRINCETON HOUSE
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:
1972712701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 17TH ST
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:
80202-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-595-4464
Provider Business Mailing Address Fax Number:
303-595-9225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3884 W PRINCETON CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80236-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-761-1460
Provider Business Practice Location Address Fax Number:
303-761-3619
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WHELAN
Authorized Official First Name:
TERI
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
303-595-4464

Provider Taxonomy Codes

  • Taxonomy code: 3104A0625X , with the licence number:  AL-0197 , 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: 40030849 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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