1609415181 NPI number — PARKVIEW ANCILLARY SERVICES

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 1609415181 NPI number — PARKVIEW ANCILLARY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKVIEW ANCILLARY SERVICES
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:
1609415181
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:
408 NORTH MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81003-3123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-595-7417
Provider Business Mailing Address Fax Number:
719-542-0809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3676 PARKER BLVD.
Provider Second Line Business Practice Location Address:
STE. 310
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81008-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-595-7780
Provider Business Practice Location Address Fax Number:
719-595-7789
Provider Enumeration Date:
12/31/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DARRIN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SR VP/COO
Authorized Official Telephone Number:
719-584-4290

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9000152520 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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