Provider Demographics
NPI:1306831250
Name:COLORADO WEST OTOLARYNGOLOGISTS, PC
Entity Type:Organization
Organization Name:COLORADO WEST OTOLARYNGOLOGISTS, PC
Other - Org Name:REGENESIS PLASTIC SURGERY & SKIN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-245-2400
Mailing Address - Street 1:2515 FORESIGHT CIRCLE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1018
Mailing Address - Country:US
Mailing Address - Phone:970-245-2400
Mailing Address - Fax:970-242-9092
Practice Address - Street 1:2515 FORESIGHT CIRCLE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1018
Practice Address - Country:US
Practice Address - Phone:970-245-2400
Practice Address - Fax:970-242-9092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04007308Medicaid
CO04007308Medicaid