Provider Demographics
NPI:1528026804
Name:WESTERN COLORADO RADIATION ONCOLOGY, PC
Entity Type:Organization
Organization Name:WESTERN COLORADO RADIATION ONCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ARCHULETA
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, ROCC
Authorized Official - Phone:970-257-1786
Mailing Address - Street 1:2352 N 7TH ST
Mailing Address - Street 2:STE. B
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8168
Mailing Address - Country:US
Mailing Address - Phone:970-257-1786
Mailing Address - Fax:970-257-0035
Practice Address - Street 1:2352 N. 7TH ST.
Practice Address - Street 2:STE. B
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501
Practice Address - Country:US
Practice Address - Phone:970-257-1786
Practice Address - Fax:970-257-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO007210174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04017604Medicaid
CO179008OtherBLUE CROSS - BLUE SHIELD
COCG0832OtherRRMCR
COCG0832OtherRRMCR
COCG0832OtherRRMCR