1255733374 NPI number — WESTERN INFECTIOUS DISEASE INFUSION CENTER, INC.

Table of content: (NPI 1255733374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255733374 NPI number — WESTERN INFECTIOUS DISEASE INFUSION CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN INFECTIOUS DISEASE INFUSION CENTER, 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:
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:
1255733374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1449
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEAT RIDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80034-1449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-425-9245
Provider Business Mailing Address Fax Number:
303-425-1378

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3303 W 144TH AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
BROOMFIELD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80023-9464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-425-9245
Provider Business Practice Location Address Fax Number:
303-425-1378
Provider Enumeration Date:
09/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DESJARDIN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PHYSICIAN/PRESIDENT
Authorized Official Telephone Number:
303-425-9245

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C377608 . This is a "MEDICARE GROUP NUMBER" identifier . This identifiers is of the category "OTHER".




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