Provider Demographics
NPI:1851399646
Name:NORTHWEST REGIONAL ASC, LLC
Entity Type:Organization
Organization Name:NORTHWEST REGIONAL ASC, LLC
Other - Org Name:NORTHWEST REGIONAL AMBULATORY SURGERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:10170 CHURCH RANCH WAY
Mailing Address - Street 2:STE 110
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-6058
Mailing Address - Country:US
Mailing Address - Phone:303-328-3400
Mailing Address - Fax:303-328-3401
Practice Address - Street 1:10170 CHURCH RANCH WAY
Practice Address - Street 2:STE 110
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-6058
Practice Address - Country:US
Practice Address - Phone:303-328-3400
Practice Address - Fax:303-328-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16P689261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00228297OtherRAILROAD MEDICARE
CO72636076Medicaid
CO72636076Medicaid
COP00228297OtherRAILROAD MEDICARE