Healthcare Provider Details

I. General information

NPI: 1336910751
Provider Name (Legal Business Name): VISTA SURGICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E HAMPDEN AVE STE 200
ENGLEWOOD CO
80113-2788
US

IV. Provider business mailing address

PO BOX 909
COLORADO SPRINGS CO
80901-0909
US

V. Phone/Fax

Practice location:
  • Phone: 303-788-5300
  • Fax: 303-788-5363
Mailing address:
  • Phone: 719-576-4171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CASSANDRA LANE REYNOLDS
Title or Position: CEO
Credential: MD, FACS
Phone: 303-788-5300