Healthcare Provider Details

I. General information

NPI: 1275943201
Provider Name (Legal Business Name): MSK MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROADWAY A-100
DENVER CO
80203-3959
US

IV. Provider business mailing address

1 BROADWAY A-100
DENVER CO
80203-3959
US

V. Phone/Fax

Practice location:
  • Phone: 303-455-6345
  • Fax: 303-455-6343
Mailing address:
  • Phone: 303-455-6345
  • Fax: 303-455-6343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number38790
License Number StateCO

VIII. Authorized Official

Name: W RAFER LEACH
Title or Position: OWNER
Credential: M.D.
Phone: 303-870-8870