1700337029 NPI number — PREMIERE HEALTHCARE ASSOCIATES LLC

Table of content: (NPI 1700337029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700337029 NPI number — PREMIERE HEALTHCARE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIERE HEALTHCARE ASSOCIATES 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:
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:
1700337029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15400 W 64TH AVE
Provider Second Line Business Mailing Address:
UNIT 9 BOX 359
Provider Business Mailing Address City Name:
ARVADA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80007-6852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-918-6386
Provider Business Mailing Address Fax Number:
303-232-6201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14828 W 6TH AVE
Provider Second Line Business Practice Location Address:
SUITE 16-B
Provider Business Practice Location Address City Name:
GOLDEN
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80401-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-918-6386
Provider Business Practice Location Address Fax Number:
303-232-6201
Provider Enumeration Date:
10/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GUTIERREZ
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
303-918-6386

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  1866 , 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: 62534084 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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