MEDICARE: HIGH COUNTRY SURGICAL ASSIST

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	246ZC0007X	Surgical Assistant	2703	CO

General Provider Information

NPI Number	:	1639311004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGH COUNTRY SURGICAL ASSIST

Provider Business Mailing Address
First Line	:	7202 BUCKINGHAM PL
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80130-4169
Country	:	US
Telephone Number	:	281-462-1285
Fax Number	:	281-462-1554

Provider Business Practice Location Address
First Line	:	7202 BUCKINGHAM PL
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80130-4169
Country	:	US
Telephone Number	:	281-462-1285
Fax Number	:	281-462-1554

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RODNEY GRAVENOR
Credential	:	CSA
Telephone Number	:	281-462-1285

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	04/01/2009

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