1629600754 NPI number — CENTURA VENTURES, LLC

Table of content: (NPI 1629600754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629600754 NPI number — CENTURA VENTURES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTURA VENTURES, 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:
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:
1629600754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 801172
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-1172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-953-0104
Provider Business Mailing Address Fax Number:
303-765-6670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1263 LAKE PLAZA DR STE 210B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80906-3564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-776-3350
Provider Business Practice Location Address Fax Number:
719-776-3374
Provider Enumeration Date:
02/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
CARPENTER
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, AMBULATORY SERVICES
Authorized Official Telephone Number:
303-765-6998

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1073882197 . This is a "OLD NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9000146144 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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