=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598374647
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PORTERCARE ADVENTIST HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2020
-----------------------------------------------------
Last Update Date | 05/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9403 CROWN CREST BLVD STE 420
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80138-9049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-925-4720
-----------------------------------------------------
Fax | 303-925-4721
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 801106
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64180-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-953-0104
-----------------------------------------------------
Fax | 303-765-6670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR-OMA
-----------------------------------------------------
Name | MRS. ANGELA SKINNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-670-7175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------