Basic Information
Provider Information | |||||||||
NPI: | 1043939028 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARKVIEW ANCILLARY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 560825 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802560825 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195844045 | ||||||||
FaxNumber: | 7195420809 | ||||||||
Practice Location | |||||||||
Address1: | 525 WEST 15TH STREET | ||||||||
Address2: | STE. 300 | ||||||||
City: | PUEBLO | ||||||||
State: | CO | ||||||||
PostalCode: | 81003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195421696 | ||||||||
FaxNumber: | 7195421698 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2022 | ||||||||
LastUpdateDate: | 08/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ESTRADA | ||||||||
AuthorizedOfficialFirstName: | JAMIE | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 7195957417 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PARKVIEW ANCILLARY SERVICES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.