Basic Information
| Provider Information | |||||||||
| NPI: | 1649310111 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROWN POINT SURGERY CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CROWN POINT SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9397 CROWN CREST BLVD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | PARKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801388575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209746499 | ||||||||
| FaxNumber: | 7209746498 | ||||||||
| Practice Location | |||||||||
| Address1: | 9397 CROWN CREST BLVD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | PARKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801388575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209746499 | ||||||||
| FaxNumber: | 7209746498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | JENETHA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9727633893 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0039 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 99636247 | 05 | CO | MEDICAID |