Healthcare Provider Details

I. General information

NPI: 1639311004
Provider Name (Legal Business Name): HIGH COUNTRY SURGICAL ASSIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7202 BUCKINGHAM PL
LITTLETON CO
80130-4169
US

IV. Provider business mailing address

7202 BUCKINGHAM PL
LITTLETON CO
80130-4169
US

V. Phone/Fax

Practice location:
  • Phone: 281-462-1285
  • Fax: 281-462-1554
Mailing address:
  • Phone: 281-462-1285
  • Fax: 281-462-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number2703
License Number StateCO

VIII. Authorized Official

Name: MR. RODNEY GRAVENOR
Title or Position: PRESIDENT
Credential: CSA
Phone: 281-462-1285