=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720111321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLORADO VALLEY ANESTHESIA, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 519 SPRING ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78934-2345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-732-9218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 519 SPRING ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78934-2345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-732-9218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | JEFFREY H WHITE
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 405-744-4835
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------