Provider Demographics
NPI:1861821563
Name:CENTURA VENTURES, LLC
Entity Type:Organization
Organization Name:CENTURA VENTURES, LLC
Other - Org Name:CENTURA HEALTH PHYSICIAN GROUP PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:JARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-571-8899
Mailing Address - Street 1:1391 SPEER BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-2508
Mailing Address - Country:US
Mailing Address - Phone:303-561-5000
Mailing Address - Fax:303-561-5050
Practice Address - Street 1:3030 N CIRCLE DR
Practice Address - Street 2:SUITE 212
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1177
Practice Address - Country:US
Practice Address - Phone:719-776-4852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4569Medicare PIN