Basic Information
| Provider Information | |||||||||
| NPI: | 1992093686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ONTIVEROS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | TED | ||||||||
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| Credential: | CST, SA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 268 WESTIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOCHBUIE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806035807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035641781 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 PRAIRIE CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806014006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034981600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | N | 246ZC0007X | 15-719 | CO | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.