MEDICARE: OPTUMCARE COLORADO MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1619009388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTUMCARE COLORADO MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 35380
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89133-5380
Country	:	US
Telephone Number	:	702-579-3203
Fax Number	:	719-538-2990

Provider Business Practice Location Address
First Line	:	1633 MEDICAL CENTER PT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-1604
Country	:	US
Telephone Number	:	719-667-4146
Fax Number	:	719-520-5266

Authorized Official
Title or Position	:	ASSOCIATE DIRECTOR CREDENTIALING
Name	:	EMILY CASTILLO
Credential	:
Telephone Number	:	702-480-2550

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	10/18/2024

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