Provider Demographics
NPI:1114202041
Name:STATESERV MEDICAL OF COLORADO LLC
Entity type:Organization
Organization Name:STATESERV MEDICAL OF COLORADO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-797-8061
Mailing Address - Street 1:1201 S ALMA SCHOOL RD STE 4000
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-1148
Mailing Address - Country:US
Mailing Address - Phone:877-633-7250
Mailing Address - Fax:
Practice Address - Street 1:920 FORD ST.
Practice Address - Street 2:SUITE A
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915
Practice Address - Country:US
Practice Address - Phone:877-633-7250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE STATESERV COMPANIES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-11
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5619060001Medicare PIN