Provider Demographics
NPI:1942235759
Name:SOUTHERN COLORADO JOINT VENTURES LLC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO JOINT VENTURES LLC
Other - Org Name:FOUNTAIN DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:HILGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-280-9501
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-5893
Mailing Address - Fax:877-850-7073
Practice Address - Street 1:6910 BANDLEY DR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817
Practice Address - Country:US
Practice Address - Phone:719-393-0190
Practice Address - Fax:719-393-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22570781Medicaid
062552Medicare Oscar/Certification