Healthcare Provider Details

I. General information

NPI: 1114602596
Provider Name (Legal Business Name): COLORADO PROVIDER NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 GARRISON ST STE 110
LAKEWOOD CO
80215-4748
US

IV. Provider business mailing address

PO BOX 12375
DENVER CO
80212-0375
US

V. Phone/Fax

Practice location:
  • Phone: 720-241-3765
  • Fax:
Mailing address:
  • Phone: 970-664-2497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN EDWARD MARQUEZ
Title or Position: OWNER
Credential:
Phone: 720-241-3765