Basic Information
| Provider Information | |||||||||
| NPI: | 1982810131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOSCOPY CENTER AT PORTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 SOUTHPARK DR | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801205641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037228987 | ||||||||
| FaxNumber: | 3037222935 | ||||||||
| Practice Location | |||||||||
| Address1: | 2535 S DOWING ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037228987 | ||||||||
| FaxNumber: | 3037222935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 08/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | GOUDZWAARD | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3032051090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 40050351 | 05 | CO | MEDICAID |