1689714495 NPI number — COLORADO STATE INFUSION, 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 1689714495 NPI number — COLORADO STATE INFUSION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORADO STATE INFUSION, 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:
1689714495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17111 PRESTON RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75248-1229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-972-5888
Provider Business Mailing Address Fax Number:
866-491-5888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 N 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81501-2115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-243-3411
Provider Business Practice Location Address Fax Number:
970-243-3364
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRAYTON
Authorized Official First Name:
JOE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF STRATEGY OFFICER/EVP
Authorized Official Telephone Number:
972-588-1050

Provider Taxonomy Codes

  • Taxonomy code: 251F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PDO.0530000052 , 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: 2003295 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: PDO.0530000052 . This is a "DEPARTMENT OF REGULATORY AGENCIES" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 84152877 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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