=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902177017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIERE CONCEPTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2012
-----------------------------------------------------
Last Update Date | 04/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4080 YOUNGFIELD ST
-----------------------------------------------------
City | WHEAT RIDGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80033-3862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-462-1285
-----------------------------------------------------
Fax | 281-462-1554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5460 WARD RD. #300
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-351-7060
-----------------------------------------------------
Fax | 303-395-0826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN LANKENAU
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 281-462-1285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------