Healthcare Provider Details

I. General information

NPI: 1104242700
Provider Name (Legal Business Name): OPTUMCARE COLORADO MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 21ST ST UNIT 100
COLORADO SPRINGS CO
80904-3763
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 719-522-1133
  • Fax:
Mailing address:
  • Phone: 702-579-3203
  • Fax: 719-538-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: EMILY CASTILLO
Title or Position: ASSOCIATE DIRECTOR CREDENTIALING
Credential:
Phone: 702-579-3253