Basic Information
Provider Information | |||||||||
NPI: | 1730706607 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SCL HEALTH FRONT RANGE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LUTHERAN WEIGHT LOSS CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 3455 LUTHERAN PKWY STE 220 | ||||||||
Address2: |   | ||||||||
City: | WHEAT RIDGE | ||||||||
State: | CO | ||||||||
PostalCode: | 800336029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034033030 | ||||||||
FaxNumber: | 3034036907 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2020 | ||||||||
LastUpdateDate: | 12/22/2020 | ||||||||
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: | 12/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RB0002X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine | 208600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.