Provider Demographics
NPI:1164668216
Name:SOUTHERN COLORADO ANESTHESIA PROFESSIONAL LLC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO ANESTHESIA PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-214-2180
Mailing Address - Street 1:4100 JERRY MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1046
Mailing Address - Country:US
Mailing Address - Phone:719-214-2180
Mailing Address - Fax:
Practice Address - Street 1:4100 JERRY MURPHY RD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1046
Practice Address - Country:US
Practice Address - Phone:719-214-2180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR-38609207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty