Provider Demographics
NPI:1154357788
Name:CHERRY CREEK IMAGING, LLC
Entity type:Organization
Organization Name:CHERRY CREEK IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-355-4674
Mailing Address - Street 1:P.O. BOX 809
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-0809
Mailing Address - Country:US
Mailing Address - Phone:303-468-1395
Mailing Address - Fax:303-355-7865
Practice Address - Street 1:12687 W CEDAR DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2010
Practice Address - Country:US
Practice Address - Phone:303-355-4674
Practice Address - Fax:303-355-7865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58952225Medicaid
COC554478OtherTRAILBLAZER MEDICAR
CO554478Medicare ID - Type UnspecifiedPROVIDER NUMBER