Provider Demographics
NPI:1497157960
Name:CATHOLIC HEALTH INITIATIVES COLORADO
Entity Type:Organization
Organization Name:CATHOLIC HEALTH INITIATIVES COLORADO
Other - Org Name:CENTURA HEALTH PHYSICIAN GROUP TRI-LAKES PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OMA ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-673-7175
Mailing Address - Street 1:PO BOX 911057
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1057
Mailing Address - Country:US
Mailing Address - Phone:303-643-1099
Mailing Address - Fax:303-643-1176
Practice Address - Street 1:17230 JACKSON CREEK PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-7301
Practice Address - Country:US
Practice Address - Phone:719-571-7000
Practice Address - Fax:719-571-7059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36258857Medicaid
CO36258857Medicaid