Provider Demographics
NPI:1811999758
Name:HEART CENTER OF THE ROCKIES CATH LAB LLC
Entity type:Organization
Organization Name:HEART CENTER OF THE ROCKIES CATH LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-297-6931
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-297-6866
Mailing Address - Fax:970-297-6862
Practice Address - Street 1:2500 ROCKY MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538
Practice Address - Country:US
Practice Address - Phone:970-624-1756
Practice Address - Fax:970-624-1792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31863207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25139347Medicaid
COHE642103OtherANTHEM BCBS
COHE642103OtherANTHEM BCBS