Basic Information
| Provider Information | |||||||||
| NPI: | 1730570946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DRY SURG LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3715 W 95TH PL | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800312603 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3715 W 95TH PL | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800312603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205407155 | ||||||||
| FaxNumber: | 7205407155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2015 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | DATKHAEV | ||||||||
| AuthorizedOfficialFirstName: | ROBEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7205407155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | SA#1058 | CO | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | SA#1058 CO | 01 | CO | SURG ASSIST | OTHER |