Provider Demographics
NPI:1235828294
Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Entity type:Organization
Organization Name:PORTERCARE ADVENTIST HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:TACHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-304-7752
Mailing Address - Street 1:PO BOX 713425
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-4325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4350 LIMELIGHT AVE STE 100
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-8034
Practice Address - Country:US
Practice Address - Phone:720-330-1390
Practice Address - Fax:720-995-5206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty