=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467499699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVISTA WOMENS CARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2006
-----------------------------------------------------
Last Update Date | 07/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 HEALTH PARK DR 290
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80027-9586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-439-8910
-----------------------------------------------------
Fax | 303-439-9134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 HEALTH PARK DR 290
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80027-9586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-439-8910
-----------------------------------------------------
Fax | 303-439-9134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING
-----------------------------------------------------
Name | MIKKI BAKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-439-8910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------