Healthcare Provider Details

I. General information

NPI: 1265890917
Provider Name (Legal Business Name): OUR LADY OF HOPE MEDICAL CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7920 S UNIVERSITY BLVD STE 100
CENTENNIAL CO
80122-5103
US

IV. Provider business mailing address

7920 S UNIVERSITY BLVD STE 100
CENTENNIAL CO
80122-5103
US

V. Phone/Fax

Practice location:
  • Phone: 720-344-2680
  • Fax: 720-344-2681
Mailing address:
  • Phone: 720-344-2680
  • Fax: 720-344-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number39788
License Number StateCO

VIII. Authorized Official

Name: DR. EDWIN THEODORE ANSELMI
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 720-344-2680