Basic Information
Provider Information | |||||||||
NPI: | 1689044794 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED URGENT CARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVANCED URGENT CARE AND OCCUPATIONAL MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2801 PURCELL ST | ||||||||
Address2: |   | ||||||||
City: | BRIGHTON | ||||||||
State: | CO | ||||||||
PostalCode: | 806013551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036599700 | ||||||||
FaxNumber: | 3035588222 | ||||||||
Practice Location | |||||||||
Address1: | 3950 W 144TH AVE | ||||||||
Address2: |   | ||||||||
City: | BROOMFIELD | ||||||||
State: | CO | ||||||||
PostalCode: | 800239508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036599700 | ||||||||
FaxNumber: | 7203363989 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2015 | ||||||||
LastUpdateDate: | 03/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STOCKTON | ||||||||
AuthorizedOfficialFirstName: | ELLEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 3036599700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
ID | Type | State | Issuer | Description | 31455573 | 05 | CO |   | MEDICAID |