Provider Demographics
NPI:1801381710
Name:BLUE MOUNTAIN SURGICAL ASSISTING
Entity Type:Organization
Organization Name:BLUE MOUNTAIN SURGICAL ASSISTING
Other - Org Name:BLUE MOUNTAIN SURGICAL ASSISTING
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FABRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-436-8821
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:CO
Mailing Address - Zip Code:80614-0552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:720-552-7231
Practice Address - Street 1:13442 THORNCREEK CIR
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80241-3902
Practice Address - Country:US
Practice Address - Phone:720-436-8821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13-460246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty