Healthcare Provider Details

I. General information

NPI: 1790004612
Provider Name (Legal Business Name): MEDVACATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 CURTIS STREET UNIT #3
DENVER CO
80205
US

IV. Provider business mailing address

PO BOX 653
DENVER CO
80201-0653
US

V. Phone/Fax

Practice location:
  • Phone: 720-837-2378
  • Fax:
Mailing address:
  • Phone: 720-837-2378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. TARAS KUZIN
Title or Position: CEO
Credential:
Phone: 720-837-2378