1548633670 NPI number — INDIAN CREEK MEDICAL GROUP INC

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 1548633670 NPI number — INDIAN CREEK MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN CREEK MEDICAL GROUP 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:
6
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:
1548633670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14062 DENVER WEST PKWY
Provider Second Line Business Mailing Address:
BLDG 52, STE 150
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80401-3187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-893-8300
Provider Business Mailing Address Fax Number:
303-825-7927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14062 DENVER WEST PKWY
Provider Second Line Business Practice Location Address:
BLDG 52, STE 150
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80401-3187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-893-8300
Provider Business Practice Location Address Fax Number:
303-825-7927
Provider Enumeration Date:
11/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
TAFFS
Authorized Official First Name:
ARWYN
Authorized Official Middle Name:
BREE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
303-893-8300

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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