Provider Demographics
NPI:1174507420
Name:460TH MEDGRP-BUCKLEY
Entity type:Organization
Organization Name:460TH MEDGRP-BUCKLEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, QM/RM/MSM
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-277-9493
Mailing Address - Street 1:275 S ASPEN ST STOP 89
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-9562
Mailing Address - Country:US
Mailing Address - Phone:720-277-9493
Mailing Address - Fax:
Practice Address - Street 1:275 S ASPEN ST STOP 89
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-9562
Practice Address - Country:US
Practice Address - Phone:720-277-9493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:460TH MEDGRP-BUCKLEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-30
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1932206786OtherNPPES
CO06-16790OtherNCPDP