1770714339 NPI number — OPTUMCARE COLORADO SPRINGS, LLC

Table of content: (NPI 1770714339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770714339 NPI number — OPTUMCARE COLORADO SPRINGS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUMCARE COLORADO SPRINGS, 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:
COLORADO SPRINGS HEALTH PARTNERS, LLC
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:
1770714339
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 S CASCADE AVE
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80903-1653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-538-2900
Provider Business Mailing Address Fax Number:
719-538-2987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1625 MEDICAL CENTER POINT
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-635-5803
Provider Business Practice Location Address Fax Number:
719-448-0164
Provider Enumeration Date:
07/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LIETHEN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
952-205-6262

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , 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: 06085288 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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