1578932539 NPI number — CHERRY CREEK FAMILY MEDICINE

Table of content: (NPI 1578932539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578932539 NPI number — CHERRY CREEK FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHERRY CREEK FAMILY MEDICINE
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:
CHERRY CREEK FAMILY MEDICINE
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:
1578932539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6551 S REVERE PKWY STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTENNIAL
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80111-6410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-699-7672
Provider Business Mailing Address Fax Number:
720-699-7673

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6551 S REVERE PKWY
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
CENTENNIAL
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-699-7672
Provider Business Practice Location Address Fax Number:
720-699-7673
Provider Enumeration Date:
09/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GARBISO
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-671-3097

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APN0010276NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 82180075 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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