Provider Demographics
NPI:1003446485
Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Entity Type:Organization
Organization Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Other - Org Name:CENTURA MEDICAL GROUP PRIMARY CARE ELIZABETH
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:TACHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-304-7752
Mailing Address - Street 1:PO BOX 801106
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1106
Mailing Address - Country:US
Mailing Address - Phone:800-953-0104
Mailing Address - Fax:303-765-6640
Practice Address - Street 1:240 ELIZABETH ST STE B
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:CO
Practice Address - Zip Code:80107-7546
Practice Address - Country:US
Practice Address - Phone:303-269-2551
Practice Address - Fax:303-269-2552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-24
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty