Healthcare Provider Details

I. General information

NPI: 1235003351
Provider Name (Legal Business Name): BESPOKE ANESTHESIA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 GRANT AVE
LOVELAND CO
80538-8412
US

IV. Provider business mailing address

400 10TH ST E
WACONIA MN
55387-4552
US

V. Phone/Fax

Practice location:
  • Phone: 970-622-0608
  • Fax: 952-442-3620
Mailing address:
  • Phone: 952-442-9770
  • Fax: 952-442-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MYA J MONTOYA
Title or Position: MANAGING MEMBER
Credential: CRNA
Phone: 404-840-3413