Basic Information
| Provider Information | |||||||||
| NPI: | 1104462597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARKVIEW ANCILLARY SERVICES | ||||||||
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| OtherOrganizationName: | PARKVIEW ADULT MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58 CLUB MANOR DR | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957417 | ||||||||
| FaxNumber: | 7195420809 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 WEST 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957585 | ||||||||
| FaxNumber: | 7195957589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2019 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DARRIN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP/COO | ||||||||
| AuthorizedOfficialTelephone: | 7195844290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARKVIEW ANCILLARY SERVICES | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12701378 | 05 | CO | MEDICAID |