Basic Information
| Provider Information | |||||||||
| NPI: | 1558863415 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFELINC ANESTHESIA COLORADO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 PLAYERS CLUB PKWY STE 350 | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381258949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018441590 | ||||||||
| FaxNumber: | 8447522159 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 FAIRHURST ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807514523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705220122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2018 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | WARREN | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9012072017 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | COO | ||||||||
| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 9000161951 | 05 | CO | MEDICAID |