1578102059 NPI number — ALTITUDE KIDNEY HEALTH PLLC

Table of content: (NPI 1578102059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578102059 NPI number — ALTITUDE KIDNEY HEALTH PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALTITUDE KIDNEY HEALTH 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:
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:
1578102059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1260 S PARKER RD STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80231-8068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-500-3439
Provider Business Mailing Address Fax Number:
920-500-3559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 S 400 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOUNTIFUL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84010-4932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-500-3439
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/31/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKENS
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
FOUNDER OWNER
Authorized Official Telephone Number:
720-500-3439

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11249743-8905 . This is a "UT CDS NUMBER" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 11249743-1205 . This is a "UT MEDICAL LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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