Basic Information
Provider Information | |||||||||
NPI: | 1588113716 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALPINE SURGICAL ASSISTING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3475 BRIARGATE BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809204170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7192192400 | ||||||||
FaxNumber: | 7192192409 | ||||||||
Practice Location | |||||||||
Address1: | 3475 BRIARGATE BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809204170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7192192400 | ||||||||
FaxNumber: | 7192192409 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2016 | ||||||||
LastUpdateDate: | 09/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEONIER | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL / MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2103877193 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | SA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X |   | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.