1558309005 NPI number — SURFACE CREEK FAMILY PRACTICE, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558309005 NPI number — SURFACE CREEK FAMILY PRACTICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURFACE CREEK FAMILY PRACTICE, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558309005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 SW 8TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAREDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81413-3902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-856-3146
Provider Business Mailing Address Fax Number:
970-856-4385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 COTTONWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELTA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81416-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-856-3146
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
970-856-3146

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 43282067 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000145531 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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