=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407466238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | L J GOTTSCHALK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2020
-----------------------------------------------------
Last Update Date | 08/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4386 TRAIL BOSS DR
-----------------------------------------------------
City | CASTLE ROCK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80104-7512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-401-3241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 757 INTERNATIONAL ISLE DR
-----------------------------------------------------
City | CASTLE PINES
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80108-3482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-401-3241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | MR. LIONEL JOHN GOTTSCHALK IV
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 858-401-3241
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------