Provider Demographics
NPI:1689714495
Name:COLORADO STATE INFUSION, INC.
Entity type:Organization
Organization Name:COLORADO STATE INFUSION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF STRATEGY OFFICER/EVP
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-588-1050
Mailing Address - Street 1:17111 PRESTON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1229
Mailing Address - Country:US
Mailing Address - Phone:866-972-5888
Mailing Address - Fax:866-491-5888
Practice Address - Street 1:1401 N 1ST ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2115
Practice Address - Country:US
Practice Address - Phone:970-243-3411
Practice Address - Fax:970-243-3364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251F00000X, 332B00000X, 332BP3500X, 3336S0011X
COPDO.05300000523336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No251F00000XAgenciesHome InfusionGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2003295OtherPK
COPDO.0530000052OtherDEPARTMENT OF REGULATORY AGENCIES
CO84152877Medicaid