Healthcare Provider Details

I. General information

NPI: 1396207767
Provider Name (Legal Business Name): FOUNDERS - CENTURA MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4386 TRAIL BOSS DR STE A
CASTLE ROCK CO
80104-7512
US

IV. Provider business mailing address

PO BOX 848349
BOSTON MA
02284-8349
US

V. Phone/Fax

Practice location:
  • Phone: 303-688-8666
  • Fax: 303-687-8260
Mailing address:
  • Phone: 303-688-8666
  • Fax: 303-688-8260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ANGELA SKINNER
Title or Position: DIRECTOR OFFICE OF MEDICAL AFFAIRS
Credential:
Phone: 303-673-7175