Provider Demographics
NPI:1528232402
Name:SHALOM PARK PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:SHALOM PARK PROFESSIONAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STENERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-680-5000
Mailing Address - Street 1:14800 E BELLEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-2258
Mailing Address - Country:US
Mailing Address - Phone:303-680-5000
Mailing Address - Fax:303-699-4300
Practice Address - Street 1:14800 E BELLEVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-2258
Practice Address - Country:US
Practice Address - Phone:303-680-5000
Practice Address - Fax:303-699-4300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETH ISRAEL FOUNDATION FOR THE AGED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-22
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1565633207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty