Provider Demographics
NPI:1982810131
Name:ENDOSCOPY CENTER AT PORTER LLC
Entity Type:Organization
Organization Name:ENDOSCOPY CENTER AT PORTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUDZWAARD
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:303-205-1090
Mailing Address - Street 1:1001 SOUTHPARK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5641
Mailing Address - Country:US
Mailing Address - Phone:303-722-8987
Mailing Address - Fax:303-722-2935
Practice Address - Street 1:2535 S DOWING ST
Practice Address - Street 2:SUITE 320
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210
Practice Address - Country:US
Practice Address - Phone:303-722-8987
Practice Address - Fax:303-722-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40050351Medicaid
CO40050351Medicaid
COC809939Medicare PIN