Provider Demographics
NPI:1285278515
Name:PARKVIEW ANCILLARY SERVICES
Entity type:Organization
Organization Name:PARKVIEW ANCILLARY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP/COO
Authorized Official - Prefix:
Authorized Official - First Name:DARRIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-584-4290
Mailing Address - Street 1:408 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3123
Mailing Address - Country:US
Mailing Address - Phone:719-595-7417
Mailing Address - Fax:719-542-0809
Practice Address - Street 1:216 W 13TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3704
Practice Address - Country:US
Practice Address - Phone:719-595-7474
Practice Address - Fax:719-595-7199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARKVIEW ANCILLARY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07725779Medicaid