Basic Information
| Provider Information | |||||||||
| NPI: | 1114965100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA VISTA PATHOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7065 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 BLANCA AVE | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776624044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 04/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | KNAUS | ||||||||
| AuthorizedOfficialFirstName: | KENDALL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8004620975 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 220008934 | 01 | CO | RAILROAD MEDICARE | OTHER | 01731866 | 05 | CO | MEDICAID |