Provider Demographics
NPI:1013549278
Name:COLLEYVERSE IOM, LLC
Entity Type:Organization
Organization Name:COLLEYVERSE IOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTO
Authorized Official - Middle Name:C
Authorized Official - Last Name:LASTMOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-366-4777
Mailing Address - Street 1:500 THROCKMORTON STREET
Mailing Address - Street 2:UNIT 3309
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102
Mailing Address - Country:US
Mailing Address - Phone:817-908-8124
Mailing Address - Fax:817-885-7339
Practice Address - Street 1:500 THROCKMORTON STREET
Practice Address - Street 2:UNIT 3309
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102
Practice Address - Country:US
Practice Address - Phone:817-908-8124
Practice Address - Fax:817-885-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Single Specialty