Basic Information
| Provider Information | |||||||||
| NPI: | 1003015306 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTLAKE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 IVANHOE ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802205840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038887742 | ||||||||
| FaxNumber: | 3037831200 | ||||||||
| Practice Location | |||||||||
| Address1: | 7800 E ORCHARD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GREENWOOD VILLAGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801112583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037831300 | ||||||||
| FaxNumber: | 3037831200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | GHISELLI | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3038887742 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2415 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.