Provider Demographics
NPI:1285257717
Name:HERITAGE COLORADO PHYSICIAN ASSOCIATES, P.C.
Entity type:Organization
Organization Name:HERITAGE COLORADO PHYSICIAN ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRICCETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-314-7304
Mailing Address - Street 1:8510 BALBOA BLVD STE 285
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4170 S CLUB DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4363
Practice Address - Country:US
Practice Address - Phone:818-654-3465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty