Healthcare Provider Details

I. General information

NPI: 1982213419
Provider Name (Legal Business Name): PORTERCARE ADVENTIST HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9695 S YOSEMITE ST STE 255B
LONE TREE CO
80124-2890
US

IV. Provider business mailing address

PO BOX 801106
KANSAS CITY MO
64180-1106
US

V. Phone/Fax

Practice location:
  • Phone: 720-455-3775
  • Fax: 720-455-3795
Mailing address:
  • Phone: 800-953-0104
  • Fax: 303-765-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELA SKINNER
Title or Position: ADMINISTRATOR- OMA
Credential:
Phone: 303-673-7175