Basic Information
| Provider Information | |||||||||
| NPI: | 1699182857 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTURA HEALTH PHYSICIAN GROUP LONE TREE PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911244 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802911244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036431040 | ||||||||
| FaxNumber: | 3036431176 | ||||||||
| Practice Location | |||||||||
| Address1: | 9695 S YOSEMITE ST | ||||||||
| Address2: | SUITE 255 | ||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801242888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036493900 | ||||||||
| FaxNumber: | 3036493910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2014 | ||||||||
| LastUpdateDate: | 07/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | SKINNER | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OMA/ ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3036430925 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.