Provider Demographics
NPI:1689837692
Name:PALISADES AT BROADMOOR PARK LLC
Entity type:Organization
Organization Name:PALISADES AT BROADMOOR PARK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-576-0178
Mailing Address - Street 1:230 EAST CHEYENNE MTN BLVD
Mailing Address - Street 2:PALISADES AT BROADMOOR PARK
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906
Mailing Address - Country:US
Mailing Address - Phone:719-576-0178
Mailing Address - Fax:719-576-1818
Practice Address - Street 1:4547 PALISADES PARK VIEW
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-226-2273
Practice Address - Fax:719-576-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center