Provider Demographics
NPI:1578515367
Name:BLACK CANYON SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:BLACK CANYON SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-249-6842
Mailing Address - Street 1:611 E. STAR CT.
Mailing Address - Street 2:SUITE C
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-6701
Mailing Address - Country:US
Mailing Address - Phone:970-249-6842
Mailing Address - Fax:970-249-6942
Practice Address - Street 1:611 E. STAR CT.
Practice Address - Street 2:SUITE C
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-6701
Practice Address - Country:US
Practice Address - Phone:970-249-6842
Practice Address - Fax:970-249-6942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0539261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67515 BLOtherANTHEM BLUE CROSS BLUE SH
CO75038358Medicaid
GAP00307659OtherPALMETTO RAILROAD MEDICAR
GAP00307659OtherPALMETTO RAILROAD MEDICAR
CO=========F01OtherROCKY MOUNTAIN HEALTH PLA