Provider Demographics
NPI:1942207196
Name:GRAND VALLEY SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:GRAND VALLEY SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHWARZBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-298-7822
Mailing Address - Street 1:710 WELLINGTON AVE STE 21
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6102
Mailing Address - Country:US
Mailing Address - Phone:970-298-7800
Mailing Address - Fax:970-298-7850
Practice Address - Street 1:710 WELLINGTON AVE STE 21
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6102
Practice Address - Country:US
Practice Address - Phone:970-298-7800
Practice Address - Fax:970-298-7850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1611ND261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1611NDOtherSTATE OF COLORADO DEPT OF PUBLIC HEALTH AND ENVIRONMENT ASC LICENSE
CO25273388Medicaid
COCA61054Medicare ID - Type UnspecifiedPROVIDER #
CO06C0001054Medicare Oscar/Certification