Provider Demographics
NPI:1750517561
Name:CANON CITY CO MULTI SPECIALTY ASC LLC
Entity type:Organization
Organization Name:CANON CITY CO MULTI SPECIALTY ASC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:ATTN: LICENSURE AND CERTIFICATION DEPT
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-263-4011
Mailing Address - Fax:
Practice Address - Street 1:933 SELLS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4900
Practice Address - Country:US
Practice Address - Phone:719-275-6433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16J165261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06C0001114Medicare Oscar/Certification
COCOB4875Medicare PIN