Basic Information
| Provider Information | |||||||||
| NPI: | 1457335077 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DENVER EYE SURGERY CENTER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13772 DENVER WEST PKWY STE 120 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032796600 | ||||||||
| FaxNumber: | 3032799140 | ||||||||
| Practice Location | |||||||||
| Address1: | 13772 DENVER WEST PKWY | ||||||||
| Address2: | BLDG#55, STE#120 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032796600 | ||||||||
| FaxNumber: | 3032799140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECKER | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3032738774 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | N | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 04510087 | 05 | CO | MEDICAID | 427718 | 01 | CO | LEGACY TM | OTHER | 490000347 | 01 | RAILROAD MEDICARE | OTHER | CK2878 | 01 | CO | LEGACY JS | OTHER | 803688 | 01 | CO | LEGACY NM | OTHER | 803092 | 01 | CO | LEGACY RK | OTHER | CK2868 | 01 | CO | LEGACY VC | OTHER |