Provider Demographics
NPI:1720127483
Name:FRONT RANGE ORTHOPEDIC SURGERY CENTER LLC
Entity type:Organization
Organization Name:FRONT RANGE ORTHOPEDIC SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEMCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:CPA MBA
Authorized Official - Phone:720-494-3222
Mailing Address - Street 1:1610 DRY CREEK DR.
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-6405
Mailing Address - Country:US
Mailing Address - Phone:720-494-3222
Mailing Address - Fax:
Practice Address - Street 1:1610 DRY CREEK DR.
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6405
Practice Address - Country:US
Practice Address - Phone:720-494-3222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1133261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67986234Medicaid
CO67986234Medicaid