Provider Demographics
NPI:1962958223
Name:NORTHGLENN ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:NORTHGLENN ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMEBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHNKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-604-5000
Mailing Address - Street 1:382 S ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-3094
Mailing Address - Country:US
Mailing Address - Phone:303-604-5000
Mailing Address - Fax:720-890-0364
Practice Address - Street 1:11900 GRANT STREET
Practice Address - Street 2:#320
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80233
Practice Address - Country:US
Practice Address - Phone:303-604-5000
Practice Address - Fax:720-890-0364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000154492Medicaid