Basic Information
| Provider Information | |||||||||
| NPI: | 1609493576 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCL HEALTH FRONT RANGE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 ELDORADO BLVD STE 6300 | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800213422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032720566 | ||||||||
| FaxNumber: | 3032720390 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 EXEMPLA CIR STE 360 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800263395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034033030 | ||||||||
| FaxNumber: | 3034036907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2020 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FADDEN | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3034252410 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RB0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine |
No ID Information.