Provider Demographics
NPI:1114068376
Name:COLORADO FACIAL PLASTIC SURGERY CENTER INC
Entity Type:Organization
Organization Name:COLORADO FACIAL PLASTIC SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:J
Authorized Official - Last Name:IMOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:303-839-7980
Mailing Address - Street 1:3600 S LOGAN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3766
Mailing Address - Country:US
Mailing Address - Phone:303-839-7980
Mailing Address - Fax:303-839-7936
Practice Address - Street 1:3600 S LOGAN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3766
Practice Address - Country:US
Practice Address - Phone:303-839-7980
Practice Address - Fax:303-839-7936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COIM642698OtherBCBS
CO08671281Medicaid
COC37821Medicare PIN
COIM642698OtherBCBS