1376863761 NPI number — COR DIAGNOSTIC SPECIALISTS LLC

Table of content: (NPI 1376863761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376863761 NPI number — COR DIAGNOSTIC SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COR DIAGNOSTIC SPECIALISTS 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:
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:
1376863761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4932
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAIL
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81658-4932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-331-6098
Provider Business Mailing Address Fax Number:
970-300-1813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 BIG HORN RD
Provider Second Line Business Practice Location Address:
UNIT 2F
Provider Business Practice Location Address City Name:
VAIL
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81657-4716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-331-6098
Provider Business Practice Location Address Fax Number:
970-300-1813
Provider Enumeration Date:
06/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
SHAUN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER/SALES
Authorized Official Telephone Number:
970-331-6098

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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