1396207767 NPI number — FOUNDERS - CENTURA MEDICAL GROUP LLC

Table of content: (NPI 1396207767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396207767 NPI number — FOUNDERS - CENTURA MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNDERS - CENTURA MEDICAL GROUP 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:
1396207767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 848349
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-8349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-688-8666
Provider Business Mailing Address Fax Number:
303-688-8260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4386 TRAIL BOSS DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTLE ROCK
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80104-7512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-688-8666
Provider Business Practice Location Address Fax Number:
303-687-8260
Provider Enumeration Date:
04/03/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SKINNER
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OFFICE OF MEDICAL AFFAIRS
Authorized Official Telephone Number:
303-673-7175

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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