MEDICARE: SCLTDI JV, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory		CO

General Provider Information

NPI Number	:	1457888398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCLTDI JV, LLC

Provider Business Mailing Address
First Line	:	PO BOX 746001
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3911 AMBROSIA ST STE 104
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80109-3887
Country	:	US
Telephone Number	:	303-214-9290
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	KATE ROELLE
Credential	:
Telephone Number	:	614-689-1691

Provider Enumeration Date	:	05/22/2017
Last Update Date	:	11/06/2023

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