Basic Information
| Provider Information | |||||||||
| NPI: | 1457897159 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN VIEW MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | DAVITA MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5575 TECH CENTER DR | ||||||||
| Address2: | STE. 106 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809192353 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5014 EL CAMINO DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809182104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196357700 | ||||||||
| FaxNumber: | 7196351794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2017 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | MINEAR | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7195901177 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.