Provider Demographics
NPI:1467415950
Name:OUTPATIENT SURGERY CENTER OF LAKEWOOD LP
Entity Type:Organization
Organization Name:OUTPATIENT SURGERY CENTER OF LAKEWOOD LP
Other - Org Name:LAKEWOOD SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEDTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-5507
Mailing Address - Street 1:2201 WADSWORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-5708
Mailing Address - Country:US
Mailing Address - Phone:303-234-0445
Mailing Address - Fax:303-232-7182
Practice Address - Street 1:2201 WADSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-5708
Practice Address - Country:US
Practice Address - Phone:303-234-0445
Practice Address - Fax:303-232-7182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0672261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04510038Medicaid
COCOB4140Medicare PIN