Healthcare Provider Details

I. General information

NPI: 1235828294
Provider Name (Legal Business Name): PORTERCARE ADVENTIST HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 LIMELIGHT AVE STE 100
CASTLE ROCK CO
80109-8034
US

IV. Provider business mailing address

PO BOX 713425
CHICAGO IL
60677-4325
US

V. Phone/Fax

Practice location:
  • Phone: 720-330-1390
  • Fax: 720-995-5206
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON TACHA
Title or Position: COO
Credential:
Phone: 303-304-7752