Healthcare Provider Details

I. General information

NPI: 1952686164
Provider Name (Legal Business Name): CHINOOK HEALTHCARE IN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W S BOULDER RD SUITE 5
LOUISVILLE CO
80027-1130
US

IV. Provider business mailing address

325 W S BOULDER RD SUITE 5
LOUISVILLE CO
80027-1130
US

V. Phone/Fax

Practice location:
  • Phone: 720-458-4887
  • Fax: 720-890-6144
Mailing address:
  • Phone: 720-458-4887
  • Fax: 720-890-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. TYSON C HODGE
Title or Position: PRESIDENT
Credential:
Phone: 720-458-4887