1306123096 NPI number — AMEDCO COLORADO PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306123096 NPI number — AMEDCO COLORADO PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMEDCO COLORADO PLLC
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:
ST. LUKE'S EYE CARE & LASER CENTER
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:
1306123096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8076 W SAHARA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89117-7930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-881-0022
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1715 N WEBER ST
Provider Second Line Business Practice Location Address:
#360
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80907-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-471-4000
Provider Business Practice Location Address Fax Number:
719-632-6088
Provider Enumeration Date:
11/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PERREIRA
Authorized Official First Name:
ERICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
877-881-0022

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1306123096 . This is a "UNITEDHEALTHCARE GROUP CONTRACT" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 40322882 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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