Basic Information
Provider Information | |||||||||
NPI: | 1316480783 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OPTUMCARE COLORADO SPRINGS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DAVITA MEDICAL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 S CASCADE AVE | ||||||||
Address2: | STE 140 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809031624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195382900 | ||||||||
FaxNumber: | 7195382987 | ||||||||
Practice Location | |||||||||
Address1: | 5115 FONTAINE BLVD | ||||||||
Address2: |   | ||||||||
City: | FOUNTAIN | ||||||||
State: | CO | ||||||||
PostalCode: | 808171061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7193922000 | ||||||||
FaxNumber: | 7193926937 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2016 | ||||||||
LastUpdateDate: | 08/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LIETHEN | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 9522056262 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.