Provider Demographics
NPI:1659144681
Name:EAA CO LLC
Entity Type:Organization
Organization Name:EAA CO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGESON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:804-335-7421
Mailing Address - Street 1:7090 S UNION PARK AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-6041
Mailing Address - Country:US
Mailing Address - Phone:801-836-4323
Mailing Address - Fax:
Practice Address - Street 1:2200 E 104TH AVE STE 116
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-4402
Practice Address - Country:US
Practice Address - Phone:303-255-1077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty