Basic Information
| Provider Information | |||||||||
| NPI: | 1346631504 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTURA VENTURES, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COLORADO SPORT AND SPINE CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 912430 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802912430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036431099 | ||||||||
| FaxNumber: | 3036431176 | ||||||||
| Practice Location | |||||||||
| Address1: | 6011 E WOODMEN RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809232602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195718888 | ||||||||
| FaxNumber: | 7195718889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2015 | ||||||||
| LastUpdateDate: | 04/28/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKINNER | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OMA ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3036737175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 23402083 | 05 | CO | MEDICAID | 55131352 | 05 | CO | MEDICAID | 97572888 | 05 | CO | MEDICAID |