Basic Information
| Provider Information | |||||||||
| NPI: | 1962609560 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRONT RANGE ENDOSCOPY CENTERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 N CASCADE AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196361201 | ||||||||
| FaxNumber: | 7199550986 | ||||||||
| Practice Location | |||||||||
| Address1: | 719 N CASCADE AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809033205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194337224 | ||||||||
| FaxNumber: | 7194337225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | BHAKTASHARAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7194337224 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 16C871 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 48781339 | 05 | CO | MEDICAID |