Provider Demographics
NPI:1609319813
Name:COLT ANESTHESIA, LLC
Entity Type:Organization
Organization Name:COLT ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-331-4222
Mailing Address - Street 1:3724 N 3RD ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2034
Mailing Address - Country:US
Mailing Address - Phone:480-331-4222
Mailing Address - Fax:
Practice Address - Street 1:3724 N 3RD ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2034
Practice Address - Country:US
Practice Address - Phone:480-331-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALIBER ANESTHESIA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207L00000X207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty